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HomeMy WebLinkAbout12-7255IN THE COURT OF COMMON PLEAS OF CUMBERLAND COUNTY .:- ~ .~.-; PENNSYLVANIA OURT DNISION - ~; ` ass ~~~ ( ~~~ ~ -- FILE NO. ,~A~ .~° ~. _~ ~~ ~' IN RE: TIARRA GARLAND, a Minor `, , ~ ~~ ~? ', ~ ,. ~; ' rte. ~: ~,, .~'", , PETITION FOR MINOR'S COMPROMISE ~ :J ~~ "~~ ~" -'~ -~ -r' Petitioner, FORRY, ULLMAN, ULLMAN & FORRY, P.C., which repres~#s Progressive. ~ ~.~ ~ Q, -~, Insurance Company, avers as follows: 1. Progressive Insurance Company is authorized to underwrite automobile liability insurance within the Commonwealth of Pennsylvania. 2. Tiffany Garland is the parent and natural guardian of Tiarra Garland, a minor. 3, Tiffany Garland, the mother, and her minor child, Tiarra Garland, reside at 3899 Spring Road, Shermans Dale, Cumberland County, Pennsylvania 17090. 4. At the time of this incident, the minor child, Tiarra Garland, was 4 years old, having been born on October 3, 2005. 5. On March 5, 2010, Minor Plaintiff was a passenger in an automobile accident which occurred at the intersection of Carlisle Pike (Rout 11) and N. Locust Point in Silver Spring Township, Cumberland County, PA. 6. The vehicle which struck the vehicle that Minor Plaintiff was in was owned by a John Atticks IV who was insured for automobile liability under a policy with Progressive Insurance Company. Minor Plaintiff was a passenger in the vehicle of her father Blake Garland. A copy of the police report of the accident is attached as Exhibit "1 ". 7. As a result of the aforesaid incident, Minor Plaintiff sustained a laceration on her left forehead with resulting scarring. Photographs depicting the scarring are attached as Exhibit "1" ~ 4N-~ a~U3 '7.5~~ C~ff~dSS~tl 2~~~3b The Minor Plaintiff also sustained a fractured left clavicle. 8. As a result of the aforesaid incident, Minor Plaintiff was airlifted by helicopter treated at Penn State Hershey Medical Center in Hershey, PA, where she was seen in the emergency room and released the next day. Records from the Life Lion and Hershey Medical Center are respectively attached as Exhibits " 3" and "4". 9. She received follow-up treatment for the forehead laceration with David Goldenberg, M.D., as well. On March 12, 2010, Dr. Goldenberg noted that "[Tiarra Garland] has been doing quite well at home. Her mother states she is eating and drinking well, running around, and playing normally. She is wearing a sling for a left clavicle fracture. Her parents deny any other medical problems.... Her skin laceration has some crusting that was cleaned off with peroxide and water. The incision appears very well healed. Her sutures were removed today with nice appearing healing ..." A true and correct copy of Dr. Goldenberg's report dated March 12, 2010, is attached hereto as Exhibit "5", and made a part hereof. Unfortunately, Dr. Goldenberg has refused to provide any further documentation regarding the Minor Plaintiff's care after that date even upon being supplied with signed authorizations from Minor Plaintiff's parent. Upon the docketing of the present petition, Petitioner will issue subpoenas to obtain complete documentation from Dr. Goldenberg and supplement this Petition. 10. Upon information and belief, Minor Plaintiff was also treated by Dr. Kerry M. Fagelman, 260 N. 3rd St., Harrisburg, PA on March 11, 2010 for a follow up for the clavicle injury. Unfortunately, Dr. Fagelman has refused to provide any further documentation regarding the Minor Plaintiffs care after that date even upon being supplied with signed authorizations from Minor Plaintiffs parent. Upon the docketing of the present petition, Petitioner will issue subpoenas to obtain complete documentation from Dr. Fagelman and supplement this Petition. 11. Upon information and belief, Minor Plaintiff was also treated by Dr. Douglas Armstrong, 30 Hope Dr., Hershey, PA on March 11, 2010 for a follow up for the clavicle injury. Unfortunately, Dr. Armstrong has refused to provide any further documentation regarding the Minor Plaintiff s care after that date even upon being supplied with signed authorizations from Minor Plaintiff s parent. Upon the docketing of the present petition, Petitioner will issue subpoenas to obtain complete documentation from Dr. Armstrong and supplement this Petition. 12. Upon information and belief, Minor Plaintiff was also treated by Dr. Fred Fedok, 500 University Dr., Hershey, PA on April 6, 2010 for a follow up for the clavicle injury. Unfortunately, Dr. Fedok has refused to provide any further documentation regarding the Minor Plaintiffs care after that date even upon being supplied with signed authorizations from Minor Plaintiffs parent. Upon the docketing of the present petition, Petitioner will issue subpoenas to obtain complete documentation from Dr. Fedok and supplement this Petition. 13. Upon information and belief, the medical bills for the care of the aforementioned providers was paid by the Commonwealth of Pennsylvania, Deparhnent of Public Welfare which is exerting a lien in the amount of $4,628.77. A copy of documents related to this lien are attached as Exhibit "6". 14. A settlement has been negotiated as a result of the aforementioned incident between Tiffany Garland, parent and natural guardian of the minor child, Tiarra Garland, and Progressive Insurance Company, which underwrote an automobile liability policy of insurance, policy No.50085966-1 on behalf of its insureds, John Peter Atticks Nand Karleigh Lenker. 15. In the negotiated settlement between Tiffany Garland and Progressive Insurance Company, Progressive has agreed to pay the sum of twenty-one thousand eight-hundred thirteen dollars ($21,813.00) to the minor child, Tiarra Garland, in full, final and complete settlement of any and all claims against John Peter Atticks Nand Karleigh Lenker under the aforesaid insurance policy resulting from the incident on March 5, 2010. 16. John Peter Atticks, N and Karleigh Lenker are provided insurance coverage via a policy through Progressive Direct with limits in the amount of $25,000/accident and $50,000/occurrence. See Exhibit "7". Neither John Peter Atticks, N and Karleigh Lenker have any other applicable insurance. See affidavits attached as Exhibit "8". 17. The Minor's applicable UIM carrier, Westfield Insurance Company, has waived any right of subrogation against Prudential in relation to this settlement and consents to same. See Exhibit "9". 18. Minor Plaintiff does not have an attorney of record for this claim. 19. All parties believe that this settlement proposal is in the best interests of the minor child, Tiarra Garland. The parent and natural guardian of Miss Garland, Tiffany Garland, is aware that if the Court approves the proposed settlement, no further claims arising from this incident can be raised against Progressive Insurance Company or its insureds, John Peter Atticks, N and Karleigh Lenker. 20. Upon approval of the within proposed settlement, Tiffany Garland shall be authorized to execute the appropriate Releases in favor of Progressive Insurance Company and John Peter Atticks IV and Karleigh Lenker, and further authorized to mark the within action, "settled, discontinued and ended" in the Docket of the Court of Common Pleas, County of Cumberland, Commonwealth of Pennsylvania. WHEREFORE, Petitioners respectfully requests this Honorable Court to enter an Order approving the settlement in the amount of Twenty-one Thousand Eight-hundred Thirteen dollars ($21,813.00) for the minor child, Tiarra Garland, which has been acknowledged by all parties as full and fair compensation to the minor child in view of the extent of her injuries. Respectfully submitted, Y. P l Date: ~ ~ ~.-~ ~" ~ BY: MICHAEL F. SCHLEI H, SQUIRE Attorney I.D. No. 88407. ATTORNEYS FOR PROGRESSIVE INSURANCE CO. VERIFICATION I, MICHAEL F. SCHLEIGH ESQUIRE and the law firm, FORRY, ULLMAN, ULLMAN & FORRY, P.C., attorneys for Erie Insurance Company, verify that the statements made in the foregoing Petition are true and correct. I understand that false statements made herein are subject to the penalties of 18 Pa. C.S. §4904 relating to unsworn falsification to authorities. MICHAEL F. SCHLEIGH, Date: ~ ~ 2 ~ ( 2 IN THE COURT OF COMMON PLEAS OF BERKS COUNTY PENNSYLVANIA ORPHANS' COURT DIVISION FILE NO. IN RE: TIARRA GARLAND, a Minor PROOF OF SERVICE I, MICHAEL F. SCHLEIGH, Esquire, and Forry, Ullman, Ullman & Forry, P.C., hereby certify that a copy of the Petition for Minor's Compromise was served via Sheriff addressed as follows: TIFFANY GARLAND 3899 Spring Rd. Shermans Dale, PA 17090 BARBARA WITMER Commonwealth of Pennsylvania Department of Public Welfare Bureau of Program Integrity Division of Third Party Liability Casualty Unit PO Box 8486 Harrisburg, PA 17105-8486 Claim No. 10-4708775 BY: MICHAEL F. SCHLEIGH, ESQUIR Date: ~ c /Z ~ // Z EXHIBIT "1" I' a i a~ a~ v a.. v r •~ (, L. v_ // 1 J ~. I L I\ J I I l- 19 ~1 I V L 1 V I_ _...~ C~RRPAOAIlillt`ALT41 ®F PIrWV~SYL!/d~R11~ p~E.ICE C6t<0SH PdE~RTBFIIG F06tPfl Page Case Gosed Reportahle Crash ~' 500 ~~ O Y85 Q No O Yes Q No 1 I.`b" miuiiuuuiiimum ......._ ~ IrKident Number Police A envy Pa4rol Zone - ~ SIL2010-03-184 21212T~ L.~ ® Agency Name Precinct Envesti anon Date (MM-DD-YYYY) ~' Silver Spring Township 212 ~ 03 - OS ~ 2010 g s d~ Dis etch Mme mil Artival Time mr Investi ator p ( ) ( n Badge Number 1747 1752 WILLIAM A BURGER TR 2407 ~ Reviewer Bad a Number Ap covet Date (MM-DO-YYYY) Q- LEROY L IIIPPENSTEEL II ~ 03 - 10 2010 Cou County Name Munici I' IiRunicipali Name - - Aay o3 NNeek a 21 ~berland 1 212 ilver Spring Township ~ O sun O Thu { O F i O M z Crash Da4e (MM-DD-YYYY) Crash Time (mip No of Untts Peo a Injured KilEad• •If > 00 r on i 03 e OS - 2010 1747 2 6 5 0 wmpiete O Tue O sat Form F O W~ O Unk WortaoneFa~ M ~~ron z9) Q Yes O No R~~ ~ Q Yes O No R~ one O Y~ O ~ ~if~P~~Id00TO Yes Q No a ~ 3 hrtersecNon Tvoe Multi-leg ~ ; O 4 Way Intersection O `Y' Intersection O O Off Ramp O Railroad Crossing ~` Intersecton O Midblock Traffic Circle/ O 'T' Intersection O Round About O On Ramp O Crossover O Other • _ Smm ®H_@Pia~ RouteRou4e N Segmen Tra s 5 Limk O North _ kouse Number (if applicable) ~ ~~ 0011 OS 45 a ~ O South A Street Name Street Ending ~ ~ O East Q For Mid-bloat arches ony. use ostal House Number and make wre ~ 6 CARLISLE PK ~ yyen Q Unknown p Princi l pa Roadway Street Name is filled in if using this optron I O nterstate ~ O Turnpike O Turnpike O State O County O local Road O Prroate O Other/ (Not Tumpike) (EastJWest) Spur Ni hwa Raad or Street Road Unknown _ " Route Number ant (Optional) Twvel Lanes Speed Umit O Narth C~ ~ 02 35 ~ Q south Stree4 Name Street Ending ~ O East s N. LOCUST POINT ~ ~ O west O O Unknown ~ 3 Ssag O Interstate O Tumpike O Turnpike O State O County. O LocaiRoad O Private O Other/ ~ (Not Tumpike) (East/West) Spur Highway Road or Street Road Unknown Intteersecting Rt Num Or Mite post Or Se meet Marker -`'-~ ~ ~ ~ th o N Feet `~ " .~ ~ . ~ _ I . J ~' or O South Or Intense Street Name _ _ P~~ ~ 54 Endin ~ O East Enter ~ Or M~7es ~ I~ormation E m O West ~ s °p fa BOTH °C ^ ~ a Landmarks H Using This Opilon Intersecdn Rt Num Or Mile Post Or Segment Marker _ ~ e O North O ~ ~ ~ • Distance From Crash S d k W . O South cene to Lan t mar ~ E Or Intersecting Street Name St Endin ~ '~ O East (For Crash between ® ~ ~ ~ O West Landmark T and Landmark 2) r ~ Degrees Minutes Sewnds Degrees Minutes Seconds -- Latitude: ~ ~~~.~ Longitude: ~ ~ ~~. Traffic Con m/ Det>ice O Yield Sign O Police Officer or LCD Fjl~p - r ~ O Not Applicable O Traffic Signal O Active RR Crossing O ~~n TCD Controls ~ O No Controls O ID~ro erlnctioning O p ~emPtn e mP P y Flashing Traffic ~ Signal O Stop Sign O Passive RR ~ Unknown Crossing Controls Signal O Device Not ~ Device Functioning O Unknown Functioning PropeNy Lie dosed (/t 'Not Rpplicable", skip nit of the Lane Closure section) lave Closure Q North ~) East Q North and South Q Al~l O Not Applicable O Partially Q Fully Q Unknown i~ Q South (N,S,E,Nh l O West O East and West d I[a~s Yes O No O ~~ Unknown O ~ O < 30 Min. O 30-60 Min. O 13 hrs O 3-6 hrs Q 6-9 hrs O > 9 hours O Unknown ~....- .....-~w r I~~r PEiVNbOY COPY i ?( 1 http://www.d~t ~.:~~w~P.z,a.us/crsapp/PrintImages/XmlFiles/20100241402010031014403440... 3/10/2010 wldr, iu. LV!J? L,4Lrlvi ~1LVtn arr<>ivu ru± 1~r_ ....« .,..., ,. C..~.~_ I cC~f>Zfil®R9Qft4C~,ffli9 ~Df~ ff'{~RHf~S?8.99~F1idG~1 J ~~8~ ~~69 R~6~YBRlGr ~®R~J ,; ,,. AA 5002 Pakeuseonly .__ __~.._._-~~ ~_ ' ;. , 'J ., ~ ~, , i ~~ II~~I~~~~~III~I~I~1~1~ Crash Number 4'•101 'd93. e Motor vehicle in Hit & Run Vehicle ~ Tvpe O Transport O O Illegally Parked O Legally Parked ONon -Motorized ' Commerda/ Vehicle ra Unit Pedestrian on Skates, Disabled From O Pedestrian O ~ Train O Phantom Vehide O O ves O No in Wheelchair, etc Previous Crash (!f Yes, Complete Form C) (If 'Pedestrian' or "Pedestrian on Skates, in Wheelchair, etc", Com fete Form M, Section 18) Unit No First Name MI Date of Birth (MM-DD-YYYY) Ol KARLEIGH ~ ~ 20 1988 Delete? last Name Tele hone Number - p LENKER 7173869263 ~ Address / Ci /State 2i ° 7229 SLEEPY HOLLOW RD HARRISBURG PA 17112 Driver License Number State Class 28352425 PA " AlcvhoUDnras suspected Driver or Pedestrian Physiwl Condition ~ No III I Dru Medicaton O O~ 9s O Apparently illegal Drug O Normal O Use O Fatigue O Medication ~ O Alcohol O Alcohol and Drugs O Unknown Had Been O Sick Q Asleep O Unknown O Drinkin 'S~ p Altohd Test Tyne O Test Not Given Q Breath O Other PNma-V Vehide Code Violation Charged? ~ if O Blood Q Urine O T~k TRAFFIC CONTROL SIGNALS O ves O No G y Alcohol Test Results O Test Refused O Unknown Results prhrer Presence 1=Driver Operated 3=Driver Fled Scene ~~ ~ O Test Given, i d R C t h ~ Vehicle 4=Hit and Run ontam na e esu S 2=NO Driver 9=Unknown Owner/Ddver 00=Not Applicable 02=Private Vehide Not 04=State Poise Vehide 07=Municipal Police Veh 09=Federal Gov Veh 01=Private Vehicle Owned/ OwnedAeased by Driver 05=PENNDOT Vehicle 08=Other Municipal 98--Other 02 Leased by Oriver 03=Rented Vehide 06=Other State Gov Veh Government Vehicle 99=Unknown Sarne as Owner First Name Owner Last Narrre or Business Name pf Pedestrian, skip this Section) ___ Driver p JOHN PETER ATTICKS IV Address / / State /Zip Vehicle Make *Make Code 155 AMY DR CARLISLE PA 17013 Chevrolet ~ 20 VIN Model Year Vehide Model (see overlay) 1998 BLAZER license Plate Req. State Est. Speed Vehide Towed Towed By HLK4520 PA 999 Q ves O No MILLER & SAM'S Insurance Insurance Company Pdicy No p ves O No O known PROGRESSIVE ~~ 50085966-1 r $ T Ifnd T 1=Towing Pan. Veh 4=Mobtle/Modular Home 7=Semi-Trailer Tag Na Tag Year Tag St Un No. of ^ U-~ ^ 2=Towing Truck S=Camper B=Other ~ ~~ a ts g 3sTowing Utility Trailer 6=Full Trailer 9=Unknown Unl ~ i Direction of S •Vehide Position ~ •ANovement ravT-T- ~ ~ Ol ~ *See O l Special Usa°e ver ay Vehide Color Vehicle Tvpe OS--Large Truck 20=Unicycle, Bicycle, ~ i2=Commercial 06=YHlow 03 07=Silver 01=Automobile ~=SUV Tricycle Ol 02=Motortyde 07=Van 21 tether Pedaltyde Passenger 00=Not Applicable Carcier 01 Fi h 08=Gold 01=Slue 09=Brown 03--Bus 10=Snowmobile 22=Horse & Buggy 04=Smal) Trusts 11=farm Equip 23=Horse & Rider = re Ve 13=Taxi OZ-Ambulance 21=Tractor Trailer ' 02=Red 10=Orange (If °OZ ;Complete Form 12=Construction Equip 24=Tram 03=Police 22= 11nrin Trailer 03=White 1 t~urple M, Section 26J 13=AN 25=Trolley o8=Other Emergency 13=Triple Trailer 04=Green 12=Other 05=Slack 99=Unknown IS=OtherT $ Veh 98--Other (U "20" or 1?', Complete 1g3Unk Type $ e~c Veh 99 Unk Vehicle 31=MOdifiedVeh 11=Pupil Transport 99=Unknovm . p = nown Form M, Secton Z7) Initial Impact Point Damage Indictor Gradient 3=Downhill Road Allanment 12 OO~Jon-Collision 14=Undercarriage Ot-t2=Clock Points 15=Towed Unit O=None 2=Functional ~ 1=Minor 3~isabiing 4=Bottom of Hill ~ 1=level 5 To of Hill 1=Straight ~ 2 C d 13 T k 9=Unknown - 2sUphill k urve = = op 99=Un nown g=Un nown 9=Unknown rvnN r wasw qz~ PENNDOT CQPY http://www.dot6.state.pa.1~/ ,-;;~4 i >. ... r' ~C~, ,, ,.i'- . '. `~ . >.." ;' .. ,~~. .. .,. ,%: `/ '1.~. v cC®Glfdf~fdC?~9@~9~~46U ®fF 1~~9~~T0.99t~6319G~1 ~~9~E ~~~8$ R~~$~9Rlfa ~R~ Page: AA 500 2 ~~ use ooy .~ t t t -. ..•v i ~' ~i.;l / 5~ uuiiimui~un ,....._ ~ W0148935 Motor Vehide in O Hit & Run Vehide O Illegally Parked O Legally Parked ONon -Motorized O Commercial Vehicle e ~ ~, Transport Tvpe Unit Pedestrian on Skates, Disabled From O Train O Phantom Vehide --- (:} Pedestrian O O O Yes O No ~ Previous Crash in Wheelchair, etc (If Yes, Complete Form C) ~ (ff "Pedesirran' or "Pedestrian on Skates, in Wheelchair, etc', Complete Forrn M, Section 28) Unit No First Name Nil Date of F3irth (MM-DD-YYYl~ 02 CHRISTOPHER _ 12 06 1985 Last Name Tele hone Number Delete? O KNOUSE 7177134596 Address ! Ci /State Zi °- 829 BOILING SPRINGS RD MECHANICSBURG PA 17055 Driver License Number State Class g 28546669 PA AlcohabDrugs Suspected Dr/ver or Pedestrian Phvslpf Conditfon O No O Illegal Drugs O Medicaton O NAop~raelnUY O ~seegei 0~9 O Fatigue O Medication ~ O Alcohol O Alcohd and Drugs O Unknown Had Been O Sidc O Asleep (~ Unknown ~ Drinkin ~ (~ Almhof Test Type O Test Not Given O Breach O Other Prtmarv Vehide Coale VfolaUon Charged) ~ O Blood O Urine O 7 ~~ ~~if RESTRAINT SYSTEMS O Yes O No y Alcohol TestResu/ts O Tert Refused O Resuuwn DrlverPresence 1=Driver Operated 3=Driver fled Scene 0 03 O Tert Given, ^ ~ C i t d R h 1 Vehide 4=Hit and Run ~ • ontam na e esu s 2=No Driver 9=Unknown OwnedDriver 00=Not Applicable 02=Private Vehicle Not 04=State Poise Vehide 07=Municipal Police Veh 09=federal Gov Veh 01=Private Vehcle Owned/ OwnedAeased by Driver OS~ENNDOT Vehicle 08=Other Munidpal 98=Other 02 Leased by Oriver 03=Rented Vehicle 05=Other State Gov Veh Government Vehicle 99=Unknown Same as Ovvner First Name Owner Last Name or Business Plama (tf Pedestrian, skip this Section) ~~ giver O MANTEL D KNOUSE Address / / State /Zip Vehicle Make *Malte Lode 829 BOILING SPRINGS RD MECHANICSBURG PA 17055 Honda ~ 37 VIN llAodel Year Vehide Model (see o`fe~Y) 1995 CIVIC License Plate Reg. State fst. Speed Vehicle Towed Towed By HKB6686 PA 999 O Yes O No MILLER & SAM'S Insurance Insurance Company Policy No ~ Y~ O N0 O known STATE FARM 7312112B1038H Trolling T 1=Towing Pazs. Veh 4=MObile/MOdular Home 7=Semi-Trailer Tag No Tag Year Tag St -~ N f i ~ o. o Un t ^ 2=Towing Truck S=Camper 8=Other (~ ~ a ^ U g U rt ~ 3=Towing Utility Trailer 6=Full Trailer 9=Unknown LJ n s Direction of ~ 'Vehicle Position Ol *Agovement T- i' Ol °See Spedal Usage e rav Overlay Vehicle Color Vehide Tvrse OS--large Trvck 20=Unicycle. Bicycle, ~ 12=Commerdal Passenger 06=Yellow 12 07=Silver 01=Automobile ~=SW Triryde Ol 02=Motor de 07=Van 2t=Other Pedal de ~ 00=Not Applicable Carrier Ot=Fire Veh 13=Taxi 08=Gold 10=Snowmobile 22=Horse & Buggy 03=Bus ' 02=Ambulance 21=Tractor Trailer 01=Slue 09=Brown OZ=Red iO=Orange rcier 04-Small rrudc 11=Farm Egvip 23=Horse & R Complete form 12=Construction Equip 24=Train (If °02" 03=Police 22=Twin Trailer 03=White 11=Purple , M, Secfion 26) t3=ATV 25=Trolley 08=Other Emergency 23=Triple Trailer Vehicle 31=Modified Veh 04=Green 12=0tlter 05=Black 99=Unknown i8=Other T e S Veh 98--Other (d "10" or 21 ;Complete 19=Unk Type Spe Veh 99=Unknown i 1=Pupil Transport 99=Unknown . Form M, Section 27) lrtftial lmoad Point Damage indicator Gradient 3=Downhill Road Allgnntent 00=Non-Collision 14=Undercarria 09 01-12 k Point T Clo 15 d Unit O=None 2~unctional ~ 1=Minor 3=Disabling 4=Bottom of Hill D 1=Level S=To of Hill 1=Straight ~ 2=Curved = = owe c s 9=Unknown 2=Uphill k k 13=Top 99=Unkrwwn g=Un nown 9=Un nown FORK f AA~SOD (t2/D2) PENN©OT CCI:PY r CClflld4iilO~FfUEA~SQ~U OF ~'E~16~~V~!ltA~l6A PCt~,IC~ CRf#5~1 ~~Pf9B8~'16~G ~~~flfl i~'~ ~~ ~ ~.,.~. .,1 / IIIIIIPIIIIIpIbY ,......... ~ :'.' U L fG;'~JJ Person Tvne: Seat Posihbn: A t=Driver ~ 00=Not A PassenggedOccupant ~.~.i;V~p~'inmen t One: ~ E 00=None Used /Not Applicable h ld l U d B _ ~ ion: ~ ~~~~ ~j O=Not Applicable Not Ejected 1 2=Passenger 7=Pedestrian 01=Driver -All Vehicles 02~ront Seat Middle Position er e se 01=S ou t 02=Lap Belt Used = 2=Totally Eyeded B=Other 9=Unknown 03=Front Seat Right Side 04=Second Row -left Side Or 03=Lap And Shoulder Belt Used 04=Chid Safely Seat Used 3=Partially Ejected 9=Unknown Motorcycle Passen er 05=Second Row - Midgdle Position OS=Motorcycle Helmet Used 06=6i de Helmet Used ~{ El~g~ Path: ~. Q F =Female 06=Second Row -Right Side 07=Third Row Or Greater - 10=Safety Belt ltsed Improperly 1 t=Child Safety Seat Used Improperly O=Not Ejected /Not Applicable 1=Through Side Door Opening g ® ~ M=Male U =Unknown Left Side Og=p~ird Row Or Greater - 12=Helmet Used Improperly 90=Restraint Used, Type Unknown 2=Through Side Window 3=Through Windshield ra Middle Posftion 09=Third Row Or Greater - 99~Unknown 4=Through Back Door S=Through Bads Der Tai ate Opening e m ~ O=NOt Iniure ~ Right Side 10=Sleeper Section of Truckcab 11=In Other Enclosed ~Ly Eouioment Two; 6=Through Roof Openin Sunroof/ I F OO:Notte Used /Not Applicable Convertible Top Down Ot mFront Alr Bag Deployed (For This Seat) 7=Through Roof Opening (Convertible ~ 1=Killed 2=Major Injury Passenger Or Cargo Area 12=1n 0 Area 02=Side Air Bag Deployed (For This Seat) To U ) 03=Other Type Air gag Deployed 4=Unknown Air B ed tG l Oe i 04 M 3mModerate In ury ~ (Bade Of Pickup, Etc.) 13=Trailing UnR i hicl E t idi e ags p oy = u p 05=Motorcycle Eye Protection Elbow/KneelPads Bic clist Wearin 06 a= inor Injury B=Injury, Unk er or t4~t x ng On Ve e 45=Bus Passenger y g = 10~1ir Bag Not Deployed, Switch On ~ 0 livable Seventy 9=Unknown rf 96=Otlter 99=Unknown 11=Air Bag Not Deployed, Switch Off 12=Air Bag Noi Deployed, Unk Swtch Se ' 1=Not Extricated 2mExtricated By MechanicaE Means l h Injury t3=Air Bag Remov~Prior To Crash) anica Means 3=Freed By Non -Mec g~~r 19=Unknown tf Atr Bag Depoyed 99=Unknown 9.Unknown ENfls Agency: SILVER SPG. AMB. ASS ~ Medical Facility: HOLY SPT./UNIVERSITY MEDICAL Unit No Person No r Ol Ol Date of Birth (MM-DD-YYYY) A B C ~~ ez ~ - 20 - 1988 la ~ Oa D E F ~G h 1 Ol 03 Ol L„J a Name /Address !Phone EMS Transport ~ same as LENKER, KARLEIGH K 7229 SLEEPY HOLLOW RD HARRISBURG PA 1 Q y~ O No Operator Y Unit No Person No 02 Ol Date of Birth (MM-DD-YYYY) A 8 C ~p.~ 12 - 06 - 1985 la M~ 4a ii I D (~E ~ F G Ol L" I Ol a ~ a Name 1 Address 1 Phone EMS Transport ~ same as KNOU SE, CHRISTOPHER 829 BOILING SPRINGS RD MECHANICSBURG O es O No Y Operator ~ Unit No Person No Delete? Oate oP Birth (MM-DD-YYYY) A B C 02 02 O 10 - 25 - 2001 ~ ~ a D E F G H ! 03 03 ~ 0~ Oa 0~ Name 1 Address /Phone EN15 Transport ~ same as BLAKE GARLAND 3899 SPRING RD SHERMANDS DALE PA 1709() 717 O Yes O No Operator ' Unit No Person No 02 03 Deletel Date of Birth (MM•DD•YYYY) A 8 C O 03 - Ol - 2007 2^ F~ 9~ G H I D E F OS 99 00 0~ 0~ 0~ Name !Address !Phone Elvis Transport Same as Operator CADENCE KNOUSE 3899 SPRING RD SHERMANS DALE PA 17090 717 O Yes O No ~ Unit No Person No 02 04 Date of Birth (MM-DD-YYYY) A B C Dp 7 ~ - 11 - 2009 2~ ~ 9~ E F G H I D L:~ 11 L.~..~.I a a Name ! Address i Phone Elvis Transport ~ Same as LEXIE KNOUSE 3899 SPRING RD SHERMANS DALE PA 1 7090 71 771 Operator O Yes O No Unit No Person No 02 OS Date of Birth (MM-DD-YYY1~ A B C Oelete? O 10 - 03 - 2005 2~ F^ ~ D E F G H I 04 ~ 11 ~ ~ 0^ Name /Address !Phone ENAS Transport ~ Same as TTARRA GARLAND 3899 SPRING RD SHERMANS DALE PA 17090 717 p Yes O No Operator Foam x nn•soo Iruoz} PIJdNDaT COPY ~.f-~ ~~~. ~_ :,~1 1, J .v. -.~. _ ~,~ i ~®~`i~®4~4R1~A~TP~ ®~ ~~f~I~~Z(1.~~~~ ~~~~~~~~~~~~~~~~~~~~ Crash Number •~J F~®LI~~ CR@,~Q-0 R~~~6~'B'IR4G ~Ru~fd rave .. • ,. I _ ._ ._-. ~t,~~~ , Crash Description f ~ ~ 0=Non-Collisioi r 2=f lead On 4 Mylo S=Sidesw~'pe 8 Hit Podesirian u 1=Rear End 3=Rear to Rear 5 Sideswipe (Oppo>;?te Direction) c a __ (Bat3Cing) (Same Direction) 7=H"d Fixed Object 9-OtheriUnknown Relation to Raadwav ~ 1=at Travel Lanes 3=Median 5=Outside Trafficway 7=C,ore (Ramp Intersection) ~; ° 0 2=Shoulder 4=Roadside 6=1n Parking Lane 9=Unknown iI is r N/umination i~DayQght 3=Dark-Street 5=0awn &=Other 1~ 2=Dark - No L+ghts 6=Dark -Unknown ~' ~ ~ --^--- _ Street Lights a=Dusk _ Roadway LighGnJq ~• ~-_---.-_.---._--_.__..__-_•-- -'I _ _ _ .... S Weather Conditions -a t ~~ 3~Sleet (Hail) S=Fog 7=Sleet & Fog ' 9=Unknown - -li 6-Rain & F m ~ _-_-- 2=Flakt a=Snow og Other RoadSuriaceCondlNons Q l}=Dry 2=Sand, Mud, Dirt, 4=3~sh 6=lce~~P~atches 8=Other `~'I _ ~ i=Wet 3=Snow Covered 5=~e _ 7 or Movir ding -__..-__._ _..._.-.._ . -~ Harm Event 1 R pAost7 Ry Poke Number yarmful Events fkarm Event) 3D=Hit Fence Or Wall 9 02 ^ O ~~ 01=Hit Unit 1 31=Hit Building Unit No 02=Hit Unit 2 32=Hit Culvert Ol 2 ~ ^ O 03=Hit Unit 3 33=Hit Bddge Pier Or Abutment 04=Hit Unit 4 34=Hit Parapet End 05=lilt Unit 5 35=Hit Bridge Rail 06=Hit Other Traffic UnR 36=Hit Boulder Or ObstacEe Please Put 07=Flit Deer On Road 3 ^ A Events in O 08~1d Other Animal 37~1iF impacwt ayttenuator SeGuentia/ 09=Collision With Other Non 38=Hit fire Hydrant i Order fixed Object 39=1iit Roadway Equipment ~ i t=struck Unit 1 40diit Mail Box I ~ ~ 4 0 12=Stnxk By Unit Z At~l$ Traffic Island ; ss ~ 13=Struck By Unit 3 42=Hit Snow Bank ,moo Harm Event L/R iWostl Utility Pole Number 14=Struck By Unit 4 43=Hit Temporary Construction = t 5=5tnxk By Unit 5 Barrier « 1 11 o O ~ ~ 16=Stnrdc By Other Traffic Unil 48=Hit Other Fixed Object a°i Unit Pdo Z1=FGt Tree Ot ShNttbery 49=HR Unknown Fixed Object ,> 22=FFrf Embankment 50=Overturr/Rofl Over z 02 2 ~ ^ O ~ 23=Hit Ublitp Pie 51=Struck By Thrown Or Falling 24=Hit Traffic S' n Ob ect t 25=Hft Guard Rail 52=Pot Hdes Or Other ~ plcy~ p~ 3 ~ ~ ~~ 26=Hit Guard Rail End Pavement Irregularities Events in ~ 27eHk Curb 53=fackn'rfe Sequential 28mHit Concrete Or 54=Fue In Vehkfe p~~ 4 ~ ^ O ~~ Longittrdxial Barrier SS=Other Non-Collision 29=Hit Ditch 99=Unknown Harmful Event ___ __ First Unit No Harm Event Wlost Unk No Ham Evart Driver Action ID} 17=Careless Or Illegal tr }7imful ~ ~ }7-rmful ~ ~ Op=t Contributing Action Backing On Roadway Sri Ol 02 vet: nt rn Ol 02 01=Driver Was Distracted i8=Driving On The Wrong tTi ~arh er~sh 02=Driving Uswg Hand Held Phone Side Of Road 00 ~ repeat ws nrotmatia, on mp;r+k weg 03=0rivirtg Us~g Hands Free Phone 19=Making Improper Envfronmenta!/Roadway 04=Making Illegal U-Tum EnVance To Highway Pafential Factors (E/R) t 07 2 ~ 3 ~ 06.Tt~xniong from WrwTigriane 20 Fkromr Highway~r ~ 00=None 1 i=Slippery Road Conditions (ke/5now) 07=Proceeding W!0 21 scoreless Parkux3/Unparking 01=Windy Catdi6ons 12=Substance On Road Clearance After Stop 22=0verNnder 02=Sudden Weather Conditions 13=Potholes ~Y 08=Running S_ top Sign Conytensation At Curve 03=Other Weather Conditions 14=Broken Or Cracked Pavement ~=Running Red ht 10=Failure To Resp~orul7o zq~~rn~~ Fast For Conditions 04=Deer In Roadway 15=TCD Obstructed Other Traffic Cornroi Device 25~al1ure To Maintain Proper Speed OS~bstacle On Roadway t6=5oft Shoulder Or Shoulder Drap Off 11=TaBga~g 26sDriver fang Police (Poi Chase) 06~ther Animal In Roadway 28=Other Roadway factor 12=Stxfden SlevuirxyStopp~ng 27=Driver Inex fenced to 07=Glare 29=Other Environmental favor 13=lllegaily Stopped On Road per e 08=Work Zone Related 99=Unknown 14 =Careless Passing Or Lane 28=FaBure To Use Specialized Equip °- Change 92=Affected By Physical Cond~iron Possible Vehide Failures fv} 12-Wipers 15=Passing In No Passing Zone 98>-0ther Improper Dmnng Actions £ 00=None 06=Exhaust 13=Driver SeatingKonVOI 16=Driving The Wrong Way On 99~Jnknown ° 01=Tires 07=Headlights 14--Body Doors, Hood, Etc 1-Way Street ~ 02~rake System 08=Signal Ughts 15=Trai(e~r Hitdt ~ 03=Steering System 09=Other Lights 16=Wheels NUonit Ol i 99 2 ~ 3 ~ . 4 ~ 04=Suspension 10`Hom 17=Airbags I ~ 05=Power Train 11=ti1irrors 18=Trailer Overloaded r Unit 1~UnsecurPJShifted U~t v° t No Ol 1 ~ 2 ~ Trailer Load No 02 i 00 2 3 4 { 20=improper Towing 99=Un=Obstructed Windshield Padestdan Action fPl 03=Working " Unit 02 t ~ 2 ~ 00=None 04=Pushing Vehide I No 01=Entering Or Crarsing At 05=Approaching Or Leaving Vehide 5 Ified Location 06=Working On Vehicle Indicated Prime factor UnR No factor Code 02mWalking, Running, Jogging, 07=Standing I Do not .spear this erfarmatbn on Or Playing 98=Other tp moltiplepages. ~ 07 99=Unknown E / R v D P Unit No Ol ~ Unit Na 02 Q O to Q !f E/R is the Prime factor Type, leave Unit No blank voaM o an-soo (+~1 PENPiD(3T C®PY ~._~--- --_r ~__ ,~ ;,~ ...I / w„iSlviUiu,v~tucdlJ.aat (ir P~id1Ug'c'L~'eaJdif~ II~HI~~N~G~~~~~IIII1~ POLICE CR~45ii PdEPORTING FORM H ( crasiz Humber Page 500 ~ Police Use O1Jy W0148935 I ,..... .... ..~.... ...... _.1.. _.... 1 l --- -, .. .... ._.._.;........_ .....................,_..._._.i...._....;....._.... .. ... _.. _. ~ i i I i i .._,......<._ _. j........j.... _ .. _~. .. _ ... _. _.~..._ _..~._. ._.... ..t... ...y.. ...._i..._ ....... ....i. ._ 1.. _. ~... ~ I i i ~ i _ ........ ~ ................._i._._.....i_......_.:._....,..5... __ ... 3 I i. 1 .J.... .._L.,-....._i,..... ... _ ..._ ... .... ... ... _. _.. ... ... ..._ ._ ... ... ... ... ... ... i , i i s i j i ' ' ~ i i i 1 ,......_...~.._..._. _...i.. .,._._..... _.. .._,..._ ....~.... ....1.... _.j.. _ ._ ... ... 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I I.._. ....~...W .. . i._ ___'.._......~......_ .. _. _ ....i. ~.. !? i i i . i ... _.. ._ _._.i..._ .. ~.... i i i ® I i i ... ... ... ... .. ... ._ ... .. ... ... ._ ... i i ...i.... .,..j... ...,.:.... : i i i I ...: . i i ' i i i , i : i i i ~ i . .._,_ ...i.... ...i..... . ....i.... .. ....i. i i i . ...{_...~ i i i i ( 3 i i i i .,. .. ... ._ ,.. 0 i i ; i i ._..._.~..._._..J.....__.i.....__..i........._i_.........;_..........._..... _. ... ... .. ~ ... ._.....i.......;...__..........i_._ _ ... _. ... ... ... .. -;.... ....i.._ ... i.... ...i_.. ...i.... ....i.... . _i. ... _... ..i.... _ ..... 1 I - - .. _... ... ~ ...._ .. ... _. i 1 i i I _j ....I....... ........1.... .~ ~...._. ....:..... ....1.._ I 1 ..:_ ... ~.... ....: _ _ .. ..„.1.... I ...' ... ....: ~ t 1 I : I 1 1 I I .. _..~.__ ._~..... ._{.... _...j._.. ...~.... .. -.;.W .r :. ' i i i 1 i i f + ~ _ ._ .. ... ..._ ... .. -- i S i ~ i e i i i i i Witness Name Address Phone n y JIM & ANDY WENTZ 64 N. LOCUST POINT RD MECH. PA 17050 ?177669200 y BRIAN SHANNON 1277 SANDY LANE BOILING SPGS PA 1700 7172549740 Narrative and additional witnesses: Accident Investigation Notification Issued? ~ Property Damage O This accident occured at the intersection on Rt 11 and N. Locust Point Rd. Both drivers and witnesses were interviewed at the accident location. Unit 1 (Lenker) indicated that she was travelling south on Rt 11, had her sunglasses on and the visor down and was having difficulty seeing while driving into the sun. (Lenker) was not sure when initially interviewed if the traffic light for her direction of travel was red or green & related that she never saw the other car until the last second. a Unit 2 (Knouse) said that he was south on N. Locust Point Rd and that the traffic light for his direction was green and he proceeded into the intersection and was struck by Unit 1. ~ The listed witnesses related that the traffic light for Rt 11 south was red. ~ None of the children were able to be interviewed due to medical personnel attending however based on my ~ training and experiance these children were not properly seated in saftey seats. Investigation; It should be noted that three (3) police officers responded to the accident location on Rt 11 south. There was no doubt that there was a substantial glare from the sun at the time of the accident. Further investigation shows that Unit 1 (Lenker) was driving on a suspended drivers license for (20) days effective 2-25- 2010. --' PENNDOT COPY ' ~if~p:~~VJ"JJVJ.` J'.~.ola ... _ _ .. I ~~~~ r u , ~.... ...... ~~.. ~.J~C ~, .... ,,.I :.L i'. ii ~ ~ ,. I vL: VL. Crash Number: W0148935 Incident Number: SIL2010-03-184 .: 2.bo, ..1 / at~an. onlp M~ d .:.: _:_ . ..~...~.~.: :~. ~~:. EXHIBIT "2" . ' a ~~ f _::..:.. ~EV_. ~, A.,: ~ :~,~.- ~~,; , ~' i t F ~. max. ~~ ~: #~,5 EXHIBIT "3" ~~ ~' ~~ a ;~-: - _:,, ~as.,~~~ Patient Name: GA;L_n,i~'!~, "1"U` f'RA ,! Date of Birth: 10/3/2005 Lff®.UOtI .. Life lion Division 600 Unhrers Drive Hershey, PA 17033 (717-531- FAX (717j 531-0861 Transport Request: Division: CCT Air- Carlisle Request M: 100.9.0196-A Svc Oate: 03/85/201 Neme: Garland, Tierra Type: Helicopter Air- On-scene {Traum Addr: 3859 Spring Road t Priority: Emergent 3 Dispo: Patient Transported Shermans Dak, PA 17090 Ph: 717-718-41196 _ r! DOB: 10V0912008 " Name: Cumberland County Comm Ape: 4 yrs. sex: F Carllsit3, PA 17013 Ss: - - Race: White /non-Hispanic ®Sc~ne: Next of Kin: Location: ao°1a.0o~N x o77°04.7fj~w Lx County: Cumberland PA } Loc CSZ: CARLISLE, PA 17013 E-~-,r n,,,.. _ -"" Call Rcvd: 17:$4:01 on 03/06/2010 3 ~~ Name: Penn State Hershey Med Center Notify Plt: 17:84:29 on Q31b8/2010 Hershey, PA 17093 Wx Confirm: 17:134:38 unit: Emergency Department Respond: 17:57:88 Ar Bedside: 18:13:00 Rec MD: Rodger, D. Robert Liftoff: 1$:04:59 Dp Bedside: 18:Z2a6 :i Arrive 1: 18:11:00 A'r'°""'r Depart 1: '18:24:16 . Crew t: DalPeao, Mary MCD Arrive z: '18:34:81 t~~ >! Crew 2: Fioelto, Amanda AMR Depart 2; 18:38:34 Dispatch: 0 Crew 3: Arrive 3: 18:99:50 Wx Check: 0 ' -i Crew 4: Depart 3: 19:06:34 Liftoff: 7 Arrive 4: 19:19:29 Response: 10 Pilot t: Balda, Joseph Fly to ~Pt: T v Dispatcher. Alessi, Charles Fly with Pt: 10 Other Flt: 1 ti Tot Leg Time: 33 ~7 On 6cene: 13 ~~ _ _._ ~ Bedside: 9 : , fdent: N365SJ {laeuphln 366-N1~ Total Crew: 87 Loaded Miles : ZZ am (PtoP); Actual: 23 am In Service: 19:24:47 f Total Miles: 54 sm Max. Ait: 0 Completed; 15:24:47 on 03l08JZ010 ~~~ __ __ Category: Pediatric- Trauma { Pt Weigh: 1$ kg Diagrweis; Pedlatrk; Trauma' Mechanism: Accident-Motor Vehicle ~ ~ `~ ~ AlFergles: NONE , ` , ~. ~ , ,^ t Facility: HMC ~ ~ < ; ,,,~ raven[ ivame: un~~~t~,i~: u, i ~;ir~~ ~, ; ~ Date of Birth: 10/3/2005 r f=light Request Prlntoult - Rsquest ~: 1003-016a-A _ ~ _ _ --- 6 g Chief t;omplalnt: - S/P MYA Date & Time of injury! Onset: 03/Ot1/20t0 18:00 f tilstory of Preset+t illness: Life Lion 3 was dispatched for a STAT response to Sihrer Spring Township, Cumberland County to assist -~' BLS on scene with an unresponsive infant. s Upon arrival of Life Lion the crew was directed to the back of the ambulance. Report was given to Mary RN J by BLS provkters. History of Presenting Problem: Patient was a second row passenger in a car seat. The car in which patient was a passenger was t-boned on the drivers side roar door. The speed of the other vehicle is unknown. Per BLS there is approximately 8 Inches of intrusion to the rear door and the patients car seat was displaced toward the center of the vehicle. Per father, who was the driver, the patient was unresponsive for approximately one minute following the impact. Upon arrival of BLS patient was lethargic but responded appropriately when her name was called. Per BLS the father is aware that his daughter is being air lifted to Penn State Hershey. The child's mother has also been contacted. Aid Prior to Arrival: Immobilize- C-collar Applied, Wound- Bandage Application, Non-Rebreather Mask, Oxygen Prior Aid pertormed by: EMS Provider ' Physical Exam: '; ~ 18:15:00: "Skin Assessment: Pink, wamti and dry. No rashes noted. Laceration to bil forehead above the eyebrow, approximately 1/4 Inch fn length. Laceration of left side of head t/4 inch in length. Dressing applied to both, ~~ no active bleeding at lima of assessment. " Head/Face Assessment: Airway naturally patent. Oxygen mask in place. Lacerations as described previously. Teeth Intact, no blood noted in the oral pharynx. Small amount of blood noted at the side of the left Hare, no bkx~d noted In the Hares. No bbo_d or CSF noted from the ears or nose. Gervical collar In place and heed secured with straps. "Neck Assessment: Trachea mldUne with cervical collar in place. Patient denies pain to her neck. _~ " Chest/Lungs Assessment: Clear and wtth equal rise and fall of the chest. Good air exchange anterior and y laterally. No open wounds, abrasions, penetrations, collusions noted to the chest wall. Chest wall intact, non tender upon palpation. Respiratory rate 23-26 throughout transport. "Heart Assessment: Regular rate, no murmur heard. Heart rate through out transport 83-116. Blood pressure 99-126/54-85 with means 67-98. `~ '"' Abdomen Left Upper Assessment: Soft, non tender, non distended. Bowel sounds present. No nausea or ~' vomiting. No abrasions, contusions, penetrations noted. "Abdomen Left Lower Assessment: Soft, non tender, non distended. Bowel sounds present. No nausea or vomiting. No abrasions, c;ontusians, penetrations noted. . "Abdomen Right Upper Assessment: Soft, non tender, non distended. Bowel sounds present. No nausea + or vomiting. No abrasions, contusions, penetrations noted. ~ , , '" Abdomen Right Lower Assessment: Soft. non tender, non distended. Bowel sounds N~6sent. 'H~ nai:sea or vomiting. No abrasions, contusions, penetrations noted. , " GU Assessment: No blood noted around the genftal area. ~ , "Bade Cervical Assessment: Cervical collar In place. Patient denies neck pain. ' "Back Thoracic Assessment: Patient on long back board denies back pain. ~ < < < < . , , •• Back LurnbarlSacraf Assessment; Patient on long back board denies back pain. ' " ExtremUles-Right Upper Assessment: Full range of motion. Strong radial pulse. E~plllr.ry refill c 2 7;S(J6936 f~Nartri, Tierra ~'nrTe ~ ~f ~ , . FacilRy: HMC Pd;; - G ~i .43 Patient Namp: GA(~itJ!I~1D, 1~IARRA ~I ()ate of Birth: 10/3/2005 i { '; 4 Flight Request Prtntout - Reefueut i~: i U0~-Uri ttg-~4 Physical Exar~:.....contlrtued seconds. "Extremities-Right Lower Assessment: Full range of motion. Strong pedal pulse. Capillary refill < 2 seconds. `• Extremities-Left Upper Assessment: Full range of motion. Strong radial pulse. Capillary refill < 2 seconds. IV placed in ACF 20 gauge with NSS infusing without redness or edema. "' Extremities-Left Lower Assessment: Full range of motion. Strong pedal pulse. Cap~lary refill < 2 seconds. " Eyes-Lett Assessment: 2-mm, Reactive " Eyes-Right Assessment: 2-mm, Reactive, appears like a possible foreign body may be in her eye. Patient states is hurts to open her eyes. " Mental Status Assessment: Lethargic but arouses easily when her name is called. Asking appropriately for her parents end wants her blanket. "Neurological Assessment: Speech Normal, crying for her parents. "Other: Upon arrival of Life Uon patient was in complete spinal immobilization to include cervical collar and pediatric long board and was secured. Oxygen was in place with a nvn rebreather mask at 15 UM. Pest IYledical tilstoty: NONE Trsettnertt: L'rfe Lion 3 was dispatched for a STAT response In Silver Spring Township, Cumberland County to assist BLS with an unconscious infant. Upon arrival of Life Lion on scene we were directed to the ambulance. Report was given to RN DalPezzo from the BLS crew. Patient was In complete cervical spine immobilization with oxygen in place at i 5 UM via non rebreather mask. Patient was assessed by RN DalPezzo. Paramedic Rosito attached the monitor, NIBP and pulse ox for continuous monitoring during transport. Patient was removed from the ambulance and placed on Life Lbna stretcher, covered and secured with 5 straps. Oxygen therapy was continued with a portable cylinder at 15 UM. Patient was then carried by 4 providers to the aircraft, hot loaded head firs) into the primary position. Oxygen was placed on the on board system and continued at 15 UM. IV was initiated by Paramedic Rosito, 20 gauge left ACF. NSS was started at a wide open rate, NSS infusing without redness or edema. Blood glucose was done 88 mg/dL. RN DalPezzo contacted Penn State Hershey Medical Command, report was given. Upon arrival at Penn State Hershey patient was hot off loaded,oxygen was placed on a portable tank at 15 UM. Patient was taken to the trauma bay. Report was given to the trauma team. Report given to Trauma Team by DalPezzo, Mary. F Lsb Values: "` Chem: 1 t3:30 Glue ti8 "' Other: P4A 170/ 110 ]7 Noe ObOMa 1tiii PO/b~ i7 ~• 7t a<oswsl 10177 100/f3 76 ~~ 7I Aosaal 10130 711/66 70 00 17 Ya:aul VitNl _ 02 Pain Sedatla~ Notes vital 6ipw Itir aa.e SOOt 0 7 300k 0 7 100k 0 7 ~ ,- ,- SOOk 0 7 Facility: HMC Page 9 of 143 hatieni iVarnc: C~~;~,ihia), '."I. ,~ ;IiA J Date of Bii'1i1: 10/3/E 005 a -._ l i 3 b .s .f Vital Aaieeamertt Time EKG Temp GCS Score AVPU PT8 Glu Notes ihii lion. ___ ~ 6 i 16 !- 30 e6 ___ _~--~-- - - E V MGCS x -- --- ---- --._..._..-_.. _ -----. -... __._.-, _,_~_ Nrteny Mttinapement - - . f Time Method Rate Cone ETT Tnea SN Who Notes >Zk Mao-R.DSS.Ws Mosk .------ 16 0!1 _~._ _..~_. --- - -- - ---- ~ ~ ~ (-- IV FtulcM and Drip Medicatlone Time Avoesa Method Site Rate Dose Note9 -- Who RuidlMedfcation ~ _ - Irdueed Ga. _ Concentretlon . __ ... __ _ _ 1iY3a lloo^..- hripYor^2 su~t^w,Ybi C. sa ~ ~ .1/tte ! Copplia^tiao.Y Mover anttYOS'i^^t Sa0= '; !ua troroal aalo. SO.a .e iratocol Ir1t~a0iaQ orAur) Total Intake (Pre-Transport) 0 (During Transport) b0 Total Output (Pre•T-ansport) 0 (During Transport) 0 Pracedurse antd Supplies Tima Pracedurea end Supplies 8/U YVho Nolan 3slis sae- s-1 rw.d one•ia.~ _ i a _ MCD •.- ._. ---•- 3aY7a wwr^1- rYireor 2 e mn se ~» sit 1,oa^a- sot 3 r rua latS0 71ood aca.- aluao^. 1 f ]i^al ! Mot.^Y ii R/dL Iel~S n 0lt:-LO^d.d- sot 3 a MCa 6 &w~sll itlV ~'... .k C YIYYi.~i~~ LYk:.:;~i •-Z F. B l 'YS r. v~~4vY~4 Facility: HMC Pa. ~ ~ 0 of 143 Patient Name: GAFtIANl~, i~I,t~Hii J Date of Birth: 10/3/2005 FIIpM Regtt~;i PrintouY_Reque~ti v~: -y~E~.~„~°eiti~Cr~ SKiNATURES Mary DalPeuo RN Amanda Rosito NREMT-P ~, 7~A^n7 ~ n.,~.{rr~ 'rte ~ rr .,¢ r' 7 .. _.._ Facility: HMC , , , I ; ,~; i.rg EXHIBIT "4" ~~~~ Patient Name: GARLAND, TIARRA J Patient Sex: Female Patient Location: 7MBS, 7232, 01 Visit Type: Inpatient .._ ,. - .._t:..~.f~c~li~~ ~~,:~:. _,... '.-ealth Eniormation Sen~ces, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-08~0 PSUIiMC 1vIRN: 7506936 Date ofBirth: 10/3/2005 Visit Number: 10506936 D i s c h a r g e S u m m a r y D o c u m e n t ~ Final Document Electronically Signed by: per contribution per contribution Signed By: Engbrecht, Brett W {3/8/2010 12:15:09 PM); Gyorfi, Justin R (3/8/2010 8:51:48 AM) DISCHARGE SUMMARY Nsme: GARLAND, TIARRA J HMC Number: 7506936 DOB: 10/03/2005 Date of Admission: 03/05/2010 Date of Discharge: 03/06/2010 Physician: Engbrecht, Brett W Service: Peds Surgery Discharge Diagnosis: Left clavicle fracture Forehead laceration Other Diagnoses: None Surgical Procedures: Repair forehead laceration Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. Discharge Medications: 1. Cephalexin {Keflex) 250 mg by mouth every 6 hours. 2. Acetaminophen-codeine (Tylenol with Codeine oral liquid) 5 mL. by mouth every 6 hours. Brief History of Present Illness: ~ y ~ F ~ ` ~ ; The patient presents with major trauma and restrained passenger behind driver second row involved in unlatown speed ~'-bone type MVC with 8 inches of intrusion -Unresponsive for about 1 minute upon arrival of EMS -noted to have~laceretion of!eft forehead and left clavicle fracture. CT scan ruled out intracranial injury. ~ y ~ ` Hospital Course: ~ ' T_~~'sPrintec?: .5/19/_~~1D 1'i^s 1'r~°~;::d: is"';. ~~~~~~~ Patient Name: GARLAND, TIARRA J PSUHMC MRN: 7506936 D i s c h a r g e S u m m a r y D o c u m e n t ~ Final Document Electronically Signed by: per contribution per contribution Signed By: Engbrecht, Brett W {3/8/2010 12:15:09 PM); Gyorfi, Justin R (3/8/2010 8:51:48 AM) Pt was admitted to the pediatric surgery team. ENT was consulted to suture up the laceration. Ophthalmology was consulted and did an examination to rule out retained glass in her eyes. Orthopedics treated her for her left clavicle fracture. On the next day, 3/6/10, she was tolerating a regular diet, pain was controlled, and she had follow up arrangements with her subspecialty consults. She was stable for and discharged home with these follow-up appointments and a script far Keflex per ENT. Exam on Discharge: Gen: Awake, Alert, NAD HEENT: Laceration sutured, c/d/i. PERRLA. Mucous membranes moist. CN intact. Card: RRR, No r/mJg Pulm: CTAB. Now/r/r Abd: Soft, NT, ND. Ext: Patient moves all extremities spontaneously. Care Instructions: 1. Please follow up with your Pediatrician over the next week. You will need to make this appointment. 2. Please follow up with Pediatric Surgery at the time assigned (see below} 3. Please follow up with Pediatric orthopedics as instructed. You will be contacted for this appointment. 4. Please follow up with Pediatric ENT as instructed. You will be contacted for this appointment. 5. Pain Control: Please use over-the-counter Motrin and Tylenol for pain control as discussed. 6. Please have sutures removed in 5 days by your pediatrician. 7. Ok to shower or wash wound with soap and water. Do not soak in bath or swim for 7 days. Diet Guidelines: Regular as tolerated Activity Guidelines: r?ct4P-rnt~c?r 5/.(~/2~?~ :;?a..~rintecd.• I:<'5~1.... ~~t111 ~ ~U~ .C+ ~1~5 ~,., Patient Name: GARLAND, TIARRA J PSUI~MC MRN: 750b936 D i s c h a r g e S u m m a r y D o c u m e n t Final Document Electronically Signed by: per contribution per contribution Signed By: Engbrecht, Brett W {3/8/2010 12:15:09 PM); Gyorfi, Justin R (3/8/2010 8:51:48 AIVl) No weightbearing on the left arm/shoulder. Call your doctor if: Please call the hospital operator at 717-531-8521 and ask for the pediatric surgery resident on call if your child develops fevers above 102, is unable to tolerate feeds, turns blue, has increasing difficulty breathing, or other worsening or concerning symptoms. For non-urgent issues or questions, you can contact the pediatric surgery department at 717-531-8342. Other Instructions: Follow-up appointment with Pediatric Surgery in 3-4 weeks. You will be called with adate/time for followup appointment. If you have not heard back in 3-5 business days, you may call 531-8342 Follow-Up Appointments: No Follow-Up Appointments have been scheduled. r.~t~r~rtr,~,~: si~9n..~jo ...~~ ~, ~ ~-~: l:zs~+~.r Patient Name: GARLAl~~, TIARRA J PSUHMC Mkl1: "1506~:s6 D i s c h a r g e S u m m a r y D o c u m e n t ~ Final Document Electronically Signed by: per contribution per contribution Signed By: Engbrecht, Brett W (3/8/2010 12:15:09 PM); GyorB, Justin R (3/8/2010 8:51:48 AM) 398777 Electronic Signature on File CC: J Lynn Hoffman, MD 804 Belvedere Street Carlisle PA 17013 s Electronically Reviewed/Signed by: Justin R Gyorfi, MD Author Signature Dt/Tm:08.03.2010 08:51 AM Electronically Reviewed/Signed by: Brett W Engbrecht, MDCosigner Signature Dt/Tm: 08.03.2010 12:15 PM Pediatric Surgery: Drs. Robert Cilley, Peter Dillon, Kerry Fagelman, Brett Engbrecht Coleen Greecher MS RD CNSD, Janet Shields MSN CRNP, PNP-BC Lynn Simmons MSN CRNP JRG /BH DD: 03/06/10 DT: 03/08/10 08:44 Dale P7nt22: 5%19L2J10 fi;ae Printe~~.• 7:7.5 ~';/ ~ENNS7ATE HERSHEY Milton S. Hersl~~;y Patient Name: GARLAND, TIARRA J fUl=~1`~ IdC1Ga3G ....~......~.__-.-,_____~_. ................................~...._..........._.ED Discharge instructions..........~....~..._...._..___..........__........~...._.~......_.._____.... RESULT STATUS: Final DOCUMENT SUBJECT: ED Pat Edu ELECTRONICALLY SIGNED BY: ED Pat Edu Penn State Milton S. Hershey Medical Center Emergency Department Discharge Instructions Name: TIARRA GARLAND DOB: 10/3/2005 Chief Complaint: MRN: 7506936 Visit Date: 03/05/2010 18:58:00 FIN: 10506936 Current Date: 03/05/2010 20:35:11 Address: 3899 SPRING RD SHERMANS DALE PA 170900000 Phone: {717)713-4596 Primary Care Provider: Name: Hoffman, J Lynn Phone: (717) 243-1943 Emergency Department Care Providers: Primary Physician: Engbrecht, Brett W Secondary Physician: IMPORTANT: We examined and treated you today on an emergency basis only. This was not a substitute for, or an effort to provide, complete medical care. In most cases, you must let your doctor check you again. Tell your doctor about any new or lasting problems. We cannot recognize and treat all injuries or illnesses in one Emergency Department visit. If you had special tests, such as EKG's or X-rays, we will review them again within 24 hours. We will call you if there are any new suggestions. After you leave, you should follow the instructions below. ~ ` 4 r f Follow-Up Instructions TIARRA GARLAND has been given these follow-up instructions: , ` ~~ No follow up information was provided. Draf~/Tirnc* i °~~r ~4eci: ,' 3 `U/:' ~ , ...: ;: ~'- €~riritr~d RAE: `>I~in~r, Gnrstal [_ PENN~TATE HERSHEY ~.1 Mtan S. Hers~~~ ~~~~~c; ~.~i~i~;r Patient Name: GARLAND, TIARRA J n~rf~! 7!~Q3936 ED Discharge Instructions SMOKING is a major health issue. -Smoking greatly increases the risk of heart disease, cancer, and stroke. -If you and your family don't smoke, contine this healthy choice! -Remember to avoid secondhand smoke. -If you or anyone in your household does use tobacco products, please follow any smoking cessation advice/counseling you received while in the hospital. -If you would like more information about how to live tobacco-free, please call one of the numbers below. PSHMC Smoke Cessation Program 1-800-243-1455 Pennsylvania QUITLINE 1-877-724-1090 Are you or someone you love at the risk of suicide? Seek help as soon as possible by contacting a mental health professional or by calling: NATIONAL SUICIDE PREVENTION LIFELINE AT 1-800-273-8255 (TALK)/1-800-273-8255 Patient Education Materials TIARRA GARLAND has been given the following patient education materials: No instructions were provided. Patient Visit Summary TIARRA GARLAND has been given the following list of patient education materials and`f~o!fo~~-up instructions: Patient Education Materials: No instructions were provided. Follow-Up Instructions: R k~tc~/ i irnt. F'i iritea: ~.J i 3/~4~'i~~i q'i:~~! ciJ`I• .'rs~-~4~~ G'~~: .:~{~i~~er, drys@GI L PENNSTATE HERSHEY ~.1 Milton 5. Hers~~~f NI~d~~~ ~ ~~~ ~ ~ _ Patient Name: GARLAND, TlARRA J iv~f-iiV ra~3v~3G _....~_~..~._...__ --___... ...................w....._............_....,...~................._.._............a......................................................~.......~...._.............._.......~................, ED Discharge Instructions No follow up information was provided. I, TIARRA GARLAND, have received the above patient education materials/instructions and have verbalized understanding: Date Patient Signature MRN: 7506936 FIN: 10506936 Provider Signature Date l~~~.fief i irri^ k'ri:~seet~: a/~i W?/:::) iJ t::I:~4 ~°ia ~ ~'rir~tr~9 [~y: ~l~ir~~~r, f.°r~rstal L PENNSTATE HERSHEY ~.1 Milton S. ~Iershey ~I~tical Center Patient Name: GARLAND, TIARRA J MRN 750693Ea ': , ED Summary RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Trauma -major Final Trauma -major Olympia, Robert P (31512010 18:53 EST) Patient: TRAUMA, 7506936 MRN: 7506936 OOS: FIN: 10506936 Age: 110 years Sex: Unknown DOB: 1h11900 Associated Diagnoses: None Author: Olympia, Robert P Basic Information Time seen: Immediately upon arrival. . History source: EMS. Arrival mode: Air ambulance. History limltafion: None. History of Present Illness The patient presents with major trauma and restrained passenger behind driver second row involved in unknown speed T-bone type MVC with 8 inches of intrusion -Unresponsive for about 1 minute upon arrival of EMS -noted to have laceration of left forehead - no other complaints . Review of Systems Constitutional symptoms: Negative except as documented in HPI. Skin symptoms: Negative except as documented in HPI. Eye symptoms: Negative excepl as documented in HPI. ENMT symptoms: Negative except as documented in HPI. Respiratory symptoms: Negative except as documented in HPI. Cardiovascular symptoms: Negative except as documented in HPI. Gastrointestinal symptoms: Negative except as documented in HPI. Genitourinary symptoms:' Negative except as documented in HPI. Musculoskeletal symptoms: Negative except as documented in HPI. Neurologic symptoms: Negative except as documented in HPI. Endocrine symptoms: Negative except as documented in HPI. Hematologic/Lymphatic symptoms: Negative except as documented in HPI. Allergylimmunologic symptoms: Negative except as documented in HPI. Additional review of systems information: All other systems reviewed and otherwise negative. Health Status Allergies:. , , , No allergies have been recorded. ~ , ` Past MedicaU Family/ Social History Medical history ` Negative. , I~atc:l ~ ~ ~ : ~ , . ~ . ,' ~ ,'. ..... .. . , P;-int~~~.~_I E~~~: ,;ahinr:r, C;E-ystal L ~ENN~TATE HERSHEY Patient Name: GARLAND, TIARRA J MRN 7506936 .......................................................................................... ED Summary...............................,.......................`.........,, .................. Surgical history: Negative. Family history: Not significant. Social history: Reviewed as documented in chart, Familylsocial situation: Intact family. Physical Examination General: Alert, no acute distress. Vital Signs Skin: Warm, dry, pink, intact, no rash, no petechiae or purpura, 3 cm laceration of left forehead - 3 mm laceration just lateral of left eye . Head: Normocephalic, atraumatic. Neck: Supple, No lymphadenopathy. Eye: Pupils are equal, round and reactive to light, extraocular movements are intact, normal conjunctiva. Ears, nose, mouth and throat: Tympanic membranes clear, oral mucosa moist, no pharyngeal erythema or exudate. Cardiovascular: Regular rate and rhythm, No murmur, Normal peripheral pertusion, No edema. Respiratory: Lungs are clear 1o auscultation, No wheezes, tales, or fionchi. Chest wall: No tendemess. Back: Nontender. Musculoskeletal: Normal ROM, no tendemess, no swelling, pain over left clavicle . Gastrointestinal: Soft, Nontender, Non distended, No organomegaly. Neurological: Alert and oriented to person, place, time, and situation, No focal neurological deficit observed, CN II-XII intact, normal sensory observed, normal motor observed. Lymphatics: No lymphadenopathy. Psychiatric: Cooperative. Medical Decision Making Trauma team: Trauma criteria met, trauma surgeon present. Differential Diagnosis: Laceration, head injury. Rationale: Routine pediatric trauma workup ordered -labs pending - CXR demonstrates left clavicle fracture -other radiologic studies pending . Impressbn and Plan Diagnosis Faaal laceration 873.40 {ICD9 873.40) Closed fracture of the clavicle 810.00 (ICD9 810.00) Plan Condition: Stable. Disposition: Patient care transitioned to: Engbrecht, Brett W. ~ ~ ~ ' Addendum ~ ~ ' Signatures: ~ , , ~ ~ ~' , Electronically ReviewedlSigned (05-MAR-2010113.53.00) by_ ` . ~ • Robert P. Olympia, MD PENN~TA~ryE ~ERSHE•Y ~'1 ~;~~1~~n ~ ~~~ ~r~~~:~-; .~~ ~ . ~ x.11.:.. _ . Patient Name: GARLAND, TIARRA J : ~~-ti•1 r c~U:;:~:ru __.__~_w .................w.....~....~.~............~...~,....._...~..~......................_....._....._.~......w........k....,._....~.....,........._................._....._.................._....................; Patient Discharge Instructions RESULT STATUS: Final DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Smith, Barbara A (3/6/201 0 1 3:10 EST) PENN STATE MILTON S. HERSHEY MEDICAL CENTER 1-717-531-8521 PATIENT DISCHARGE INSTRUCTIONS H you have any questions, please contact your physician. Date of Admission: 03/05/2010 Date of Discharge: 03106/2010 Physician: Engbrecht, Brett W Service: Peds Surgery Discharge Diagnosis: Left clavicle fracture Forehead laceration Other Diagnoses: None Surgical Procedures: None - - ~~ Vaccinations Received This Hospital Stay: No vaccinations were given this hospital stay. • Discharge Medications: < < ~~a•iell~irnc~ i'rinted: 5/19/20 i0 ur ::.•!• :.-..: , .~•itit~::;l ~,f: ~;hinr;r, Crystal L PENNSTATE HERSHEY 1~1 N~i~ton S. Hershel M~lical Center Patient Name: GARLAND, TIARRA J MRN 750693:; _..~ ................~~.....___._....._..____._._._._..___._...........__..........._..........._............~_~_.....~._....~.~__...,~..__w......~........~......._......._........................................ Patient Discharge instructions Medication Dose Saecial Instructions cetaminophen-codeine mL by mouth every 6 hours Duration: 7 days Tylenol with Codeine oral liquid) phalexin 50 mg by mouth every 6 hours Duration: 7 days Keflex) Care Instructions: 1. Please follow up with your Pediatrician over the next week. You will need to make this appointment. 2. Please follow up with Pediatric Surgery at the time assigned (see below) 3. Please follow up with Pediatric orthopedics as instructed. You will be contacted for this appointment. Phone number is 717-531-5638 4. Please follow up with Pediatric ENT as instructed. You will be contacted for this appointment. Phone number is 717-531-5215. 5. Pain Control: Please use over-the-counter Motrin and Tylenol for pain control as discussed. 6. Please have sutures removed in 5 days by your pediatrician. 7.Ok to shower or wash wound with soap and water. Do not soak in bath or swim for 7 days. Diet Guidelines: Regular as tolerated Activity Guidelines: No weightbeaiing on the left arm shoulder. Call your doctor if: Please call the hospital operator at 717-531-8521 and ask for the pediatric surgery resident ~n cali if dour child develops fevers above 102, is unable to tolerate feeds, turns blue, has increasing difficulty tireathi~, ~c}.r other worsening or concerning symptoms. ~ ` ' ' , For non-urgent issues or questions, you can contact the pediatric surgery department at 717-531-R3~2`. `Please refer to handout Head Injury in Children given at discharge. I'rint~d I'y: ':;6;ir~^'r', ~°~ryrw•t:~l t. PENN~TAT~ HERSHEY Milt®~~. ~ ~ ~ ~~,~F^~ ~, ~Yeu~ca:r ~.;~;~_:_ :_,~ Patient Name: GARLAND, TIARRA J i~~FiN J506~30 ____~~__..~._.w .............................~.______.~~..._....~. Patient Discharge lnsfrucfions.....__...~.~__._.._.._~_.__~.._____..._.__...._.~_~_._._____...__.__ Other Instructions: Follow-up appointment with Pediatric Surgery in 3-4 weeks. You will be called with adate/time for followup appointment. If you have not heard back in 3-5 business days, you may call 531-8342 Follow-Up Appointments: Unscheduled Penn State - HMC Follow-Up Appointments Your appointment wish BRETT W ENGBRECHT has not yet been scheduled. If you have not been contacted with this appointment information within iwo business days, please call 531-1404. Discharging Provider: Gyorfi, Justin R TOBACCO CESSATION: Why Stop and How to Stop WHY STOP?? # the risks of: # # # # # ## # # # # # # ## # $4.00 per pack X 7 packs per week X 52 . $1456.00 per year • $3.50 per can/pouch X 7 cans/pouches per week X 2 . $1274.00 per year • Insurance premiums may cost more if you use tobacco products • Medical bills not paid by insurance add up in a year/lifetirne # 7 mins per smoke break X 20 smokes per day . 2.3 hours per, day . • 2.3 hours per day X 365 days .839.5 hours or 35 days per year ' << HOW TO STOP: ~ ~ ' ' # # # # # confirm your commitment to quit smoking. By replacing tli~ cost ,of~ the cigarettes with ~ ' ~ ; the cost of medication, the long term benefits will far outweigh the upfront costs! , < < . ; # with you over the phone for 4 to 5 sessions, 45 minutes each, at your convenient;p, , 1~2iF'/ ~ ~fYl~ ~"{'litt(:,1: :.DII.:II4.4J EU l)I.~'-6 L.:L~~,'. P'EN~I~~~~E HERSHE"Y` 1 ~toa~. ~. ~~,~ Patient Name: GARLAND, TIARRA J ~~~~E;i:! 7 ~0693G ...............~____.._..~..~_.....~~w__.~._.~..._........._............................................V.....~......................~.~~._.,...._.V,....._..........~...............w.~........................, Patient Discharge Insfructions and can direct you to assistance programs for smoking cessation medications if you cannot afford them. If you seek group counseling, the QUITLINE counselor can advise you of locations in your area. # a service of the U.S. National Library of Medicine and the National Institute of Health, at http://www.nlm.nih.gov/medlineplus/smokingcessation.html. # 1-800-243-1455. Da~t~~/Tir~e 6'ririeu: x/19/2010 Q7:?~? ED~'' !`pE°ir,; ~ !"'~s : {~hin~r, (,nrst~! L ~ ~ 6 V ` ~ L ~ ~ ~ i PENN~TATE HERSHEY /~M~ti~ton S. H~r~'~:~~j ~(a~l a~tr~ti:,it Patient Name: GARLAND, TIARRA J Mi~N 7~OG936 ~' I'rint~~o1 P~.+: ~hi.~~r, Gr~ssial !.. PENN~~ATE ~~~S~I~.~>~ Milto~~ ~® ersh~~ ~,. .. Patient Name: GARLAND, TIARRA J Mf3N 7506936 ...V.,........_,,,._._.._._...~.._..._.~..~~ ..........................................................CBC .~.........~......~..................,,..._...._.~_......__...............~..........~...............~ Procedure- : WBC Hgb Hct RBC MCV `MCHC MCH EKfj1N Plts Units }f/uL g/dL % M/uL fL 9/dL >. pg °fa K/uL Re#Qrer~ce l~ar-ge [,4.8-13;5] [11-14] (32-44] [4.0-5:8] [74-82J [30-34] (25-3~3] [12.13-rt6.4] [140-340] . Col{ecf~d Datefl•icrte 3/5/201018:40 EST ~ 8.4 0,- o, ;: o, 11.5 33 5 .":<,: . o, o, : N o, o, . 13.1 O1 294 01 4.23 79.2 - 34.3 ; 27.2 Pr#jGe~l AAPU Typa of Riff Irtii~natuce Gran°lo Neut% Ly~#?tt%~ 1~41i4°1~BASO% Eos% RefBf#_I~~g~::[t3,7-12::5] [0]; (25-51] (3~Fi~] [~-~f3~ [0-2] [0-6] Gollectetf p~tetrtia .. _ _ 3%5r'201018:40 EST ~ 9.701 MANUAL°1 0°1 27°1 fig"o, ~ 4oi "" poi' Oo'' Pnlure #mma# Gran, Abs Neut, Abs ; Lymph, Abs Mono, Abs. Bas+a, Aft Eas Abs RBC Morphology; Uitit~: ' K/uL K/uL KJ~L KIuL '`: f~uL..:....: K~uL Reference flange , [0.0[ [1.2-6.9] [1.7-8 8] [0.4-1 4] ~~ ~}-Q ~ [~ .~-0.8] " Colledtet#.~II~f'tt3t~ .."::: ... < ...'.: .3/5/2010 18.40 EST 0 0O1 .^_ _"2.3°1 ,.: - 5.8°t 0.301 ..--0.0°1......---QO~°1 NORMAL°1 Order Comments 01: Complete Blood Couni w Differential (CBC w Platelets and Diff) [[Lavender tube; Panel includes WBC count, RBC count, Hgb, Hct, Platelet count and Differential]] f f R• nMp t o IJatE'/TIPY'1~ PI"I~'.'~"'CI: ,.1..~../ry~,s,~ ..-,..,,~ ~~_~. Printrd lair: ~iiiner, C;~°yst~;l L . l ~. G PENf~STATE HERSHEY Milton S. Hershel 11~Iedical ~~>~~~_~ Patient Name: GARLAND, TIARRA J MRN 7506936 Chemistry Procedure Na K Glu - Units mmollL mmol/L mg/dL Reference Range (137-145] [3.5-5.1] [74-106]..: Coliectetii7atefTtme <: :3/5/2010 18:40 EST 141 O1 3.9 °z . 03 92 Order Commenis 01: Sodium Level [[Green gel tube; Test included in the Electrolytes, Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.]j 02: Potassium Level [(Green gel tube; Test included in the Electrolytes, Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.J] 03: Glucose Level [[ Green gel tube; Tesi included in the Basic Metabolic Panel, Comprehensive Metabolic Panel, and Nephrology Panel.]] Printed Qy: Shiner, Crystal l.. PE~IN~TATE HERSHEY NJCi~ton S. H~~s~~y Patient Name: GARLAND, TIARRA J MRN ~506y36 ._.....~.~........~ .................................~.._...~........_w.__..._.. .........._.._.............._.....V.,._._.~....,..,..._..._..~......_..._...._...___.._....._~.._.._............................._..........; Coagulation .: Procedur~`;.:1'T _ fNR _ RTT `ilttits ::second second Refe~e~ce F3ange~'[9.2-11.9] [0.88-1.13] [2434].: Coll~ct~i~.Datelf~rrre ~ >: 3/5/2010 18:40 EST 10.601 1.01 °t ~ 29 oz `` Order Comments 01: Prothrombin Time w/ INR (PT/INR) [[Blue tube]] 02: Partial Thromboplastin Time (PTT) [[Blue tube]] ,._. ,'itt~~.9 l,;~: ~hi~-~er, Cr},~st~.l I_ PENNSTATE HERSHEY ~11VIi~.ton ~. ~r~~_~~, r. l~Y~u~ic~i ~.:;Ylt"E~; Patient Name: GARLAND, TIARRA J iViRl~ 75QGJ36 ~~~ r ~ r r. N .<d ca L•-~ ~~li Y~+ t~jF. ...,fit: t'l:.t .e. .,F f'`-.' L:: ~..i i .:se~~.~~i F3;'~ -:ryErFr!•, .{j-yst~ _ FENf~~~ATE HER~HE~ ~! Miito~ ~. ~er~~~~r Patient Name: GARLAND, l'IARRA J fViRN 150693G ...........................~........_........................~.,..._...~.w......~.._y.......~.......,........~...,.....__...,.,.~..........._.~...................._....; fiver/Gl :.......................................................................................................,............................................... r.............,..................,..............................,.........: prt~cedure<::ALT Amylase: l.fn4ts.:vnii/L unit/L ReferenceRange (13-69] [30-110] Collected DatefTime.:> 3/5/2010 18:40 EST 37 01 46 O2 Order Comments 01: ALT Level ([Green gel tube; Test included in the Comprehensive Metabolic Panel, Hepatic Function Panel and Liver Profile]] 02: Amylase Level [[ Green Separator tube]] printed By: Shit ~cr, '.':'r~.: ....;' ! . PEN N STATE HERSHEY Milton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J ~I'1~9 750v~3~3 ..........................................~............._.................................................................................~........~_..w......................._.....~._.. Urine __ Procedure... Color (~~} 'Appear (u) Glu (u) E3li (u} Ke#ones SG Hgb (u} -Units Reference ~artge _ [NEGj (NEG] [NEG [NEG] _. Coliect~d<Daief'FinT~. , :3/5/2010 23:14 EST : YELLOW O1 CLEAR °/ NEGATIVE °1 NEGATIVE °1 TRACE ~ °t 1.025 O7 NEGATIVE °t _ ~` Proceti~re•. pH (u) _ Prot (u) Uroliili Nitrite (u) Lack i*~t ~;ed sub (u) WBG (u}. '.itrits ;:unit EU/d 1. Refare~e R~ttge]~.5-8.0]. [NEG] [0.1-1.0] [NEG] [N~G~ [NEG] [0-4] `< Collected:~#~te~m~. _,. :.., ..:., o~ _ _ o, o~ _ O1 ......o~ .:. :.: _ , of o 3/5/201023:14~EST 6.0 :NEGATIVE 0.2 :NEGATIVE NEGATIVE :NEGATIVE 5-9 Rrvicedure RBC (u) Bact (u); llrt~ts Refe~~ence Range. X0-4] [NONE} Collectetf.i:3~'t~~t~te 3!5/2010 23:14 EST 1-4 O1 MODERATE ~ °1 Order Comments 01: Complete Urinalysis (Basic&Micro) (Urinalysis, Complete (Basic&Micro)) [[Urine, sterile container]] ~,.., f7aLE'/!'iii:? ! `ri.,... :1 ., ,. . .,_ ~ . .._ . _La V"f~([~C(~C~ 11`y~: ailnin(a ~, Cr~^Stvl ~.. PENN~I~ATE HERSHEY .~~~ . . i.r-f~ _ ... . Patient Name: U.~RLAND, TiARRA J EJiItN ~:iUG936 .._...M,.._.._..~......_w ...............~~........__.~........~..._...._...._......._._._._....... Chest RESULT STATUS: Final DOCUMENT SUBJECT: X-RAY CHEST PA OR AP VIEW- PEDS ELECTRONICALLY SIGNED BY: SERVICE DATEITIME: 3/5/2010 18:42 EST X-RAY CHEST PA OR AP YIEW-PEDS PATIENT NAME: GARLAND, TIARRA J PATIENT MRN:07506936 PATIENT DOB: 10/03/2005 EXAM DATE OF SERVICE: 03/05/2010 EXAM NUMBER: 6071227 ORDERING PHYSICIAN: DEFLTI'CH, CHRISTOPHER EXAM: AP supine view of the chest Two views of the cervical spine Two views of the left shoulder Two views of the left clavicle CLINICAL HISTORY: 4year-old Trauma COMPARISON: No prior studies available FINDINGS: Chest: The cardiothymic silhouette and pulmonary vasculature are normal. There is no fa:'al opaci±y; Pleural effusion or pneumothorax seen. There is a fracture of the left clavicle with apex supefi~r, rngulat~o~. , L Yr V H !. 1. t l a' t ( t .A.:'I Vii. ~ ..~_ .... , .,./..., .. ,... .. ..~ Printed By: Shiner, Cryst~ a 1.. PENNSTATE HERSHEY i'Yle:Cl~Gclt ~~.~~~~Y_~~: Patient Name: GARLAND, TIARRA J MRN 7506936 .._.._~~_________________~_.._..._._~____.._..._..._.__..~.._..~__.___.......___...__.____._._.. Chest _~.._._~.__.~._.~__...__~.~...__.__...___~_..____~.~_............__.~...._a_......_...._... Cervical spine: The cervical spine is imaged from the craniocervical junction through T1. Vertebral body height and alignment are maintained. Disc spaces are preserved. There is straightening of the normal cervical lordosis. The pre-dens interval is normal. Left shoulder: There is a fracture of the left clavicle with apex superior angulation. Articulation of the glenohumeral joint is intact with no evidence of fracture or dislocation Left clavicle: There is a fracture of the left clavicle with apex superior angulation. Visualized aspects of the lungs are clear. Bone mineralization is normal. IMPRESSION: 1. Left clavicle fracture with apex superior angulation 2. No acute cardiopulmonary abnormality 3. Normal cervical spine; straightening of the spine likely due to cervical collar and cross table lateral positioning Dr. Alexis Shively i5 the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAFTED: 03/05/2010 07:43 PM DATE OF FINAL SIGNATURE: 03/05/201008:31 PM . t a i L V V V ~ ~ 1 a ' , DatelTima Printed: 5/1:/2010 0'l:?4 ~©"i" ~ 1:_~;;;~ :;•~ cai ; ;.~ ~;-~ , . _ . ~~ .,; Patient Name: GARLAND, TIARRA J ~I~fv 7a0G936 Head/Neck RESULT STATUS: DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: Final CT HEAD WITHOUT CONTRAST PED 3/5/2070 19:55 EST CT HEAD WITHOUT CONTRAST PED PATIENT NAME: GARLAND, TIARRA J PATIENT MRN:07506936 PATIENT DOB: 10/03/2005 EXAM DATE OF SERVICE: 03/05/2010 EXAM NUMBER: 6071232 ORDERING PHYSICIAN: DEFLITCH, CHRISTQPHER EXAM: CT OF THE HEAD AND FACIAL BONES COMPARISON: None available HISTORY: Four-year-old female child with trauma TECHNIQUE: A routine noncontrast head CT was performed with five by 5 mm sequential axial images processed using both brain and bone algorithms. A routine helical CT of the facial bones was performed imaged in sequential 1.3 mm axial slices using soft tissue and bone algorithms. Routine sagittal and coronal reconstructions were performed with 2 mm sequential slices. FINDINGS: HEAD: The gray-white differentiation is well maintained. No evidence of intracerebral hemorrhage, focal mass lesion or hydrocephalus seen. The midline structures aze nondisplaced. The ventricles aze normal in size, shape, and position. The basilar cisterns are preserved. There are no extra-axial fluid collections demonstrated. , . The posterior fossa structures are unremarkable. Mucosal thickening is seen in bilate*al maxillary sinuses. Mastoid air cells are clear. Soft tissue and osseous structures of the calvarium ire unrerriaik~able. FACIAL BONES: There are tiny hyperdense foreign bodies seen inboth eyes, in ~:he~i~l the ~~e~ial canthus in left eye and inferior conjunctival space on right side. The intraorbital contents are;unremazkable. There is no evidence of facial bone fracture. The skull base is intact. The mastoid air cells arena :r:ally aerated. Mucosal thickening is seen in bilateral maxillary sinuses. ~ . ,' ',. I'~'!'±~7'~~3CR City: rftin~f, ~"~P'v_,=:1 t. PENNSTATE HERSHEY 1~1 MittOn S. Hershey r ~ ~~ ~'" ;. i~G~,. Patient Name: GARLAND, TIARRA J MRN 7506936 Head/Neck IMPRESSION: 1) No evidence of intracranial injury seen. 2) Hyperdense foreign body seen in both eyes, in the medial canthus in left eye and inferior conjunctival space in right eye. No evidence of facial bone fracture seen. These findings were discussed with ENT resident Dr. Ronn on 03/05/2010 at 8 p.m. by Dr. Vijay. Dr. Kanupriya Vijay is the dictating neuroradiology fellow. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: NGUYEN, DAN REVIEWED AND SIGNED: NGUYEN, DAN DATE DRAFI~D: 03/05/2010 08:14 PM DATE OF FIlVAL SIGNATURE: 03/05/2010 08:40 PM t~~°ce-~/-i'iim~: F'rinsc~d: :~/~19/201~J 07:24 C-:[]"I° .`A:~i~t~_:~9 E3~i: `_~l:'c~;^E•, rn~sta.l L ~~, E ~~ << ~ ,. '...<< r,.}::.. PE~1N~~A~E H~RSH~~Y /~.1 ~/Iilton S. H~;rSh~y ~~Ied_i~~l ~~...uy~v~ ._. Patient Name: GARLAND, TIARRA J MRN 7506936 Nead/Neck RESULT STATUS: Final DOCUMENT SUBJECT: CT FACIAL BONES WITHOUT CONTRAST-PED ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: 3/5/2010 19:55 EST CT FACIAL BONES WITHOUT CONTRAST-PED PATIENT NAME: GARLAND, TIARRA J PATIENT MRN:07506936 PATIENT DOB: 10/03/2005 EXAM DATE OF SERVICE: 03/05/2010 EXAM NUMBER: 6071247 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER EXAM: CT OF THE HEAD AND FACIAL BONES COMPARISON: None available HISTORY: Four-year-old female child with trauma TECHNIQUE: A routine noncontrast head CT was performed with five by 5 mm sequential axial images processed using both brain and bone algorithms. A routine helical CT of the facial bones was performed imaged in sequential 1.3 mm axial slices using soft tissue and bone algorithms. Routine sagittal and coronal reconstructions were performed with 2 mm sequential slices. FINDINGS: HEAD: The gray-white differentiation is well maintained. No evidence of intracerebral hemorrhage, focal mass lesion or hydrocephalus seen. The midline structures are nondisplaced. The ventricles are normal in size, shape, and position. The basilar cisterns are preserved. There are no extra-axial fluid collections demonstrated. ~ ' The posterior fossa structures are unremarkable. Mucosal thickening is seen in bilateral maxillary sinuses. Mastoid air cells are clear. Soft rissue and osseous structures of the calvarium arE unrer,~iarkable. FACIAL BONES: There are tiny hyperdense foreign bodiesseen inbotheyes, imtlie -n the~medi~.l canthus in left eye and inferior conjunctival space on right side. The intraorbital contents ~ar`e;~:nremarl:able. There is no evidence of facial bone fracture. The skull base is intact. The mastoid air cells are no:_na:;ly aerated: Mucosal thickening is seen in bilateral maxillary sinuses. , ~ ~ ~ G ~. ~,:r~,: .. :.: .'.'i'. :..:.... ' PENNSTATE HERSHEY Milton S. Hershel ~Ie~~ ~? ~er~~:F ~° Patient Name: GARLAND, TIARRA J iv;i~?iV i:~~Q633G ..............~__....._._..__..._......._...__._..............~.._.__...~._~............___..... ..............__._...~_..._...~.__..V......~............~..~..___-__....__..._.._......_........._............._.....; Head/Neck IMPRESSION: 1) No evidence of intracranial injury seen. 2) Hyperdense foreign body seen in both eyes, in the medial canthus in left eye and inferior conjunctival space in right eye_ No evidence of facial bone fracture seen. These findings were discussed with ENT resident Dr. Ronn on 03!05/2010 at 8 p.m. by Dr. Vijay. Dr. Kanupriya Vijay is the dictating neuroradiology fellow. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. • DICTATED: NGUYEN, DAN REVIEWED AND SIGNED: NGUYEN, DAN DATE DRAT I'ED: DATE OF FINAL SIGNATURE: 03/05/2010 08:40 PM ,. Printed By: ~-hiRrw4~, C'~,•~:t~•;( !._ PENN~`TA~TE HERSHEY /~1 Milton S. Hershey Nledieal Center Patient Name: GARLAND, TIARRA J P~~RN 750693Fa Musculaskeletal RESULT STATUS: Final DOCUMENT SUBJECT: X-RAY SHOULDER 20R MORE VIEWS LEFT -PEDS ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: 3/5/2010 19:04 EST X-RAY SHOULDER 2 OR MORE VIEWS LEFT -PEDS PATIENT NAME: GARLAND, TIARRA J PATIENT MRN:07506936 PATIENT DOB: 10/03/2005 EXAM DATE OF SERVICE: 03!05/2010 EXAM NUMBER: 6071255 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER EXAM: AP supine view of the chest Two views of the cervical spine Two views of the left shoulder Two views of the left clavicle CLINICAL HISTORY: 4year-old Trauma COMPARISON: No prior studies available FINDINGS: ~ ' Chest: The cardiothynuc silhouette and pulmonary vasculature are normal. There is no oea1 opa`~ity,`Fleural effusion or pneumothorax seen. There is a fracture of the left clavicle with apex super.~r 3hgulatioa.. . ~ ~~,~ ,. ~,~ ,, a ~r{tc,,.9 ` ~~. ~ ~3~sE~,, r ~,r3tal L PENN~TATE HERSHEY ~1 Milton 5. Hershey Nledi~~ ~`.~x~ter Patient Name: GARLAND, TIARRA J MRN 7506936 ............................................~......._..........._.._.v....~~..........._....................._._.........._.....,.......~..._..._~._...,...~.......w......_~.....~..~...._..v............................, Musculoskeletal Cervical spine: The cervical spine is imaged from the craniocervical junction through T1. Vertebral body height and alignment are maintained. Disc spaces are preserved. There is straightening of the normal cervical lordosis. The pre-dens interval is normal. Left shoulder: There is a fracture of the left clavicle with apex superior angulation. Articulation of the glenohumeral joint is intact with no evidence of fracture or dislocation Left clavicle: There is a fracture of the left clavicle with apex superior angulation. Visualized aspects of the lungs are clear. Bone mineralization is normal. IMPRESSION: 1. Left clavicle fracture with apex superior angulation 2. No acute cardiopulmonary abnormality 3. Normal cervical spine; straightening of the spine likely due to cervical collar and cross table lateral positioning Dr. Alexis Shively is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAF'T'ED: 03/05/2010 07:43 PM DATE OF FINAL SIGNATURE: 03/05/201008:31 PM ,,,, ;` E, , Printed R~: `~~i:°"~~, C,E;~~':~? !_ PENN~~TA~E HERSHEY /~1 Milton 5. ~Iershey i~~'Y~~G~ ~efl~~~ Patient Name: GARLAND, TIARRA J ..a~....~.......~~___...._........V.. ................~,...................._............_._......._.........._....._....~..~. Musculoskeletal MRN 7506936 RESULT STATUS: Final DOCUMENT SUBJECT: X-RAY CLAVICLE LEFT -PEDS ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: 3!5/2010 19:04 EST X-RAY CLAVICLE LEFT -PEDS PATIENT NAME: GARLAND, TIARRA J PATIENT MRN:07506936 PATIENT DOB: 10/03/2005 EXAM DATE OF SERVICE: 03/05/2010 EXAM NUMBER: 6071256 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER EXAM: AP supine view of the chest Two views of the cervical spine Two views of the left shoulder Two views of the left clavicle CLINICAL HISTORY: 4year-old Trauma COMPARLSON: No prior studies available FINDINGS: Chest: The cardiothymic silhouette and pulmonary vasculature are normal. There is no ioc;al opa~ty,~pleural effusion or pneumothorax seen. There is a fracture of the left clavicle with apex superior ~a:~gulatior.~ i ' , t fi C Prin#c~d ~y: r'hin~r, c,r<<s2a:l I_ PENNSTATE HERSHEY ~1 Milton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J MRN 750936 ... ..................~_..__._.<._.............._...............V..........~_._.................................._...~........~......_.....~....~........_........~.._.~~......_.~...........~..... ..... ..... Musculoskelefal Cervical spine: The cervical spine is imaged from the craniocervical junction through Tl. Vertebral body height and alignment are maintained. Disc spaces are preserved. There is straightening of the normal cervical lordosis. The pre-dens interval is normal. Left shoulder: There is a fracture of the left clavicle with apex superior angulation. Articulation of the glenohumeral joint is intact with no evidence of fracture or dislocation Left clavicle: There is a fracture of the left clavicle with apex superior angulation. Visualized aspects of the lungs are clear. Bone mineralization is normal. IMPRESSION: 1. Left clavicle fracture with apex superior angulation 2. No acute cardiopulmonary abnormality 3. Normal cervical spine; straightening of the spine likely due to cervical collar and cross table lateral positioning Dr. Alexis Shively is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAFTED: 03/05/2010 07:43 PM DATE OF FINAL SIGNATURE: 03/05/2010 08:31 PM ~~ `,.' l ., Y, h, N /. 1. t. t. C)~telTim: ~'riritcel: ~,';_'/zu i0::~~ :zr;~ ; ._ .~ PENN~TATE HERSHE.~~ "'1 Eton S. I~f=~~~~=~:~~~ Patient Name: GARLAND, TIARRA J MHN 75(16~'3~i ...._..._~.._...~...__.~..__._~...._..~_....~__.__.....~...._...~~~ .......................... Spine RESULT STATUS: Final DOCUMENT SUBJECT: X-RAY CERVICAL SPINE LIMITED 2-3 VIEWS -PEDS ELECTRONICALLY SIGNED BY: SERVICE DATE/TIME: 3/5/2010 19:04 EST X-RAY CERVICAL SPINE LIMITED 2-3 VIEWS -PEDS PATIENT NAME: GARLAND, TIARRA J PATIENT MRN:07506936 PATIENT DOB: 10/03/2005 EXAM DATE OF SERVICE: 03/05!2010 EXAM NUMBER: 6071230 ORDERING PHYSICIAN: DEFLITCH, CHRISTOPHER EXAM: AP supine view of the chest Two views of the cervical spine Two views of the left shoulder Two views of the left clavicle CLINICAL HISTORY: 4year-old Trauma COMPARISON: No prior studies available FINDINGS: , Chest: The cardiothynuc silhouette and pulmonary vasculature are normal. There is no focal opacit5•? p'eural effusion or pneumothorax seen. There is a fracture of the left clavicle with apex superior 4r'_gulationl . YY' 4 ~LLaf ~ {~i IL 1' I ~{ Isf~~~ : :.. / ~ ~' 2iJ . . .. ... PENNSTATE HERSHEY , 1~11~/~i~.tO~n ~ . ~i~_r_ s1~~~~ `~ l~r~~~hr.~ ~y.~b~~ Patient Name: GARLAND, TIARRA J DARN 7536936 .w.---------~---._._w.._--~~--~------------~-~-~---~_.._.~.......~~.~ ........................... Spine~.._...~..~~...._.~...__~___~._._..~...~._..w_.._~._....~._...__~...~~_..~__...._...... Cervical spine: The cervical spine is imaged from the craniocervical junction through T1. Vertebral body height and alignment are maintained. Disc spaces are preserved. There is straightening of the normal cervical lordosis. The pre-dens interval is normal. Left shoulder: There is a fracture of the left clavicle with apex superior angulation. Articulation of the glenohumeral joint is intact with no evidence of fracture or dislocation Left clavicle: There is a fracture of the left clavicle with apex superior angulation. Visualized aspects of the lungs are clear. Bone mineralization is normal. IMPRESSION: 1. Left clavicle fracture with apex superior angulation 2. No acute cardiopulmonary abnormality 3. Normal cervical spine; straightening of the spine likely due to cervical collar and cross table lateral positioning Dr. Alexis Shively is the dictating resident. Finalized report status indicates the signing attending has reviewed the images and report, and agrees with the interpretation. Preliminary report status should be regarded as NOT interpreted by the attending radiologist. DICTATED: BOAL, DANIELLE REVIEWED AND SIGNED: BOAL, DANIELLE DATE DRAFTED: 03/05/2010 07;43 PM DATE OF FINAL SIGNATURE: 03/05/201008:31 PM ,< < C (* ~ Printed By: ~;~i,5:;~-, ('rtis~,~J !. PEN(~~TATE HERSHEY /~1 Mi~tan S. Hershey -~_~~°~1 ~'~ntar Patient Name: GARLAND, TIARRA J MRN 7506936 .._.~._.~........~ ...............................~..............~..._..~...._............._................~..~...............~.v...a..._~.....~..,.........~.._.........................v....................... , Child Life Program Form DOCUMENT TYPE: Child Life Program Form RESULT STATUS: Final PERFORM INFORMATION: Oberski, Dana M (3/5!2010 21:37 EST} SERVICE DATE/TIME: 3/5/2010 21:37 EST Child Life Program Form 03/05/10 09:37 pm Performed by Oberski, Dana M Entered on 03/05/1009:42 pm Child Life Program Child Life Program Preparation for diagnostic tests and/or procedures, Support Through Painful Procedures, Introduction to Relaxation/distraction techniques, Parent Support Services, Will maintain close contact for emotional support Child Life Program Comments Child Life present for trauma. Pt arrived alert and answering questions appropriately. She appeared scared and asking for mom. 1 approached the trauma litter and began introducing myself and explaining everything. She continued to ask for mom. I assured her mom would be here as soon as she could. Pt asked me to hold her hands and verbalized she was scared. 1 continued to be supportive and encouraging. I prepared pt for CT scan and accompanied her there. 1 assisted in comfort during suture repair of her facial laceration. Pt remained still for all assessments, scans, and suturing. She continually asked for family. I provided a stuffed animal for comfort and soon mom arrived. I explained admission to bosh of them and there were no further questions , or concerns. I will continue to ~ .. , follow family to assess any needs ~ ~ M that may arise. Dana Oberski, BS, CCLS ' Pager 4360 ;;~ ~. F'rint;~~:l f y: gl~iner-, C.r~~stal ~- PENN~TAT£ H£RSH£Y 1~.1 Miifion S. Hershey Medical Cenfie~~ Patient Name: GARLAND, TIARRA J MRiJ `7506936 .~ ............................~__-____....._~...._._...__~w...~.........w.......... ....................._....._...........~~ . lER Pediatrics Form DOCUMENT TYPE: IER Pediatrics Form RESULT STATUS: Final PERFORM INFORMATION: Yuhas, Erika (3/5,'2010 22:00 EST} SERVICE DATE/TIME: 3/5/2010 22:00 EST IER Pediatrics Form 03/05/1010:00 pm Performed by Yuhas, Erika Entered on 03105/1 0 1 1:21 prn Education Educational Needs Assessed Barriers to Learning Learning Preferences General Topics Yes None evident Verbal Explanation, Printed Instructions IER General Topic 000000001 at this time IER General Method 000000001 IER General Evaluation 000000001 IER General Taught 000000001 reason for C-collar to be maintained Verbal Explanation Verbalizes understanding Mother DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: IER Pediatrics Form 03/06/1010:00 am Pertormed by Yuhas, Erika Entered on 03/06/10 10:02 am Education Educational Needs Assessed Barriers to Learning Learning Preferences IER Pediatrics Form Final Yuhas, Erika (3/612010 10:00 EST} 31fil2010 10:00 EST Yes None evident Verbal Explanation, Printed Instructions Pediatric Mild Closed Head Injury IER Pediatrics Topic 000000001 IER Pediatrics Method 000000001 IER Pediatrics Evaluation 000000001 ryryIER Pediatrics Taught 000000001 Discuss safe usage of Tylenol PRN Verbal Explanation Verbalizes understanding Father, Mother ~~~ ~, 1. V ~ y 1 t , ~ f. PE~INSTATE HERSHEY ~1 Milton S. ~Ier~hey Medical ~~,x~~r Patient Name: GARLAND, TIARRA J MRN iaU~i~: ,_.~..w.. V....~.......__..._ ..............~......._..._.....~....___.~a_...................._.............___..._~_.._~..~._...__.M.......~ ......,.~~......_..._....._._..........._........~..... !ER Pediatrics Form IER Pediatrics Topic 000000004 Feeling more sleep/tired, especially at the end of the day:Closed head injury, Vomiting 2-3 times during the first few day:Closed head injury `, l~ri~ted Ley: ~hin~f•, ~r~~;st~:l t_ PENN~TATE HERSHEY Milton S. ~ers~~~~ ~`l~Yl~C1S~LS.F.Y 'vtiYii~iY~ Patient Name: GARLAND, TIARRA J MRN 7506936 ......................~.._._.~_._~....~~._~......_._........~_._...~.........._...IER Trauma Form ...~..V....._~...~.v..~....~~......~....~~...........~. DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: IER Trauma Form Final Smith, Barbara A (316/201013:45 EST) 3/6/2010 13:45 EST IER Trauma Form 03/06/10 01:45 pm Performed by Smith, Barbara A Entered on 03/06/10 01:49 pm Education Educational Needs Assessed Yes Barriers to Learning None evident Learning Preferences Verbal Explanation, Demonstration - Model Simulation, Printed Instructions Orthopaedic Trauma IER Orthopaedics Topic 000000028 State activity level: Weight bearing status IER Orthopaedics Method 000000028 Printed Instructions, Verbal Explanation IER Orthopaedics Evaluation 000000028 Verbalizes understanding IER Orthopaedics Taught 000000028 Father, Mother IER Orthopaedics Topic 000000029 State diet: IER Orthopaedics Method 000000029 Printed Instructions, Verbal Explanation IER Orthopaedics Evaluation 000000029 Verbalizes understanding IER Orthopaedics Taught 000000029 Father, Mother IER Orthopaedics Topic 000000032 Pain medications: Medications to be d/c home on IER Orthopaedics Method 000000032 Printed Instructions, Verbal Explanation IER Orthopaedics Evaluation 000000032 Verbalizes understanding IER Orthopaedics Taught 000000032 Father, Mother IER Orthopaedics Topic 000000034 Orthopaedic Clinic: 717-531-5638 (M-F 8amto4:30pm) IER Orthopaedics Method 000000034 Printed Instructions, Verbal Explanation IER Orthopaedics Evaluation 000000034 Verbalizes understanding IER Orthopaedics Taught 000000034 Father, Mother General Topics -------------- IER General Topic 000000001 Care of left forehead incision with sutures IER General Method 000000001 Printed Instructions, Verbal 4 M M ~`~ w` a'~ ?;-.,.~li'i~~~~ I''ri,~tecl: P;;1~/2,~1'.)~J~:<':~, ..~. . I~'r`yt~r.1 f"~~. "~r+it3raf-, !-'ryPt~.J I. PENN~TATE HERSHEY /~1 Milton 5. Hershey Patient Name: GARLAND, TIARRA J tv;6~i~i ',.rr1~33~ _~.._...~._.._...~..__._.._.._....~~ ...................~....._........_.._.. .................._......._..._...~~.w.w.~......M..~V.........y..~._........,........._.......,...._........ IER Trauma Form Explanation IER General Evaluation 000000001 Verbalizes understanding IER General Taught 000000001 Father, Mother IER General Topic 000000002 Keflex and tylenol # 3 prescriptions for discharge IER General Method 000000002 Printed Instructions, Verbal Explanation IER General Evaluation 000000002 Verbalizes understanding IER General Taught 000000002 Father, Mother IER General Topic 000000003 Follow up appts with peds surgery, ENT and ped s Ortho to be scheduled. How to contact MD and when to contact. Reviewd Head Injury in Children instr uctions. IER General Method 000000003 Printed Instructions, Verbal ' Explanation IER General Evaluation 000000003 Verbalizes understanding IER General Taught 000000003 Father, Mother IER General Topic 000000004 Use of left arm sling for comfort IER General Method 000000004 Verbal Explanation IER General Evaluation 000000004 Verbalizes understanding IER General Taught 000000004 Father, Mother r r ~ ~ i.iei..'/~S it .,~.... ..i ., .. .u .. e.. ~'rini~ct ~;r: SNiiner, Cr4~stal L PENNSTATE HERSHEY Nli~ton ~. Hershe~~ ~_ ,~ ^~ ~P ~' ~~ ~~ Patient Name: GARLAND, TIARRA J ivfRi~J 1506936 ...............~.._~__...__~.___...~__~~__.._..~_~_..... Incision/Wound/Tube Assessment Form ~`~~_`~""`-`~~""""`~`"~"~~~~""„",",,, DOCUMENT TYPE: Incision/Wound/Tube Assessment Form RESULT STATUS: Final PERFORM INFORMATION: Yuhas, Erika (3/6;2010 07:25 EST) SERVICE.DATE/TIME: 3/6/201007:25 EST Incision/Wound/Tube Assessment Form 03/06/10 07:25 am Performed by Yuhas, Erika Entered on 03/06/10 07:37 am Incision/Wou nd/Drain/Tubes -------------------------- IncisionMfound Care Grid 1. Incision/Wound Type Incision/Wound Location Incision/Wound Description Incision/Wound Color Incision/Wound Drainage Wound Cleansing/Irrigation I Laceration Eye, Left, Other: Above Sutured Pink None Cleaned With Peroxide, Other: 3aciiracin applied ?ACS:/k11 , 1.., 1'.. _,. e..: ../d-.,l ~4,f ~C3 .. i.E~. Printed By: Shiner, f,r ~t,-.l I_ PENIV~TATE HERSHEY 11/~~tor~ S. Hershey ~.~ ~.... ..;.,rii;.. , Patient Name: GARLAND, TIFa~-ii ~,~~ J i'vil tip! 150693G ~~._......~ ..........................~......_.__a......~..._........._........................................_...................V.,......_..~..........v.,..~...~.~.........~......................,................, Interdisciplinary Narrative Form DOCUMENT TYPE: Interdisciplinary Narrative Form RESULT STATUS: Final PERFORM INFORMATION: McNair, Julie (3/5/207 0 1 9:40 ESTj SERVICE DATE/TIME: 3/5/2010 19:40 EST Interdisciplinary Narrative Form 03/05/10 07:40 pm Performed by McNair, Julie Entered on 03/05/10 07:42 pm Interdisciplinary Narrative --------------------------- Interdisciplinary Narrative Discipline Nursing Inlerdisciplinary Narrative Text 1940 -Spoke io Corporal Burger with Silver Spring Township Police (238- 9676). Cpl Burger states pt's father was taken to Holy Spirit, and he's been trying to reach pt's mother via cell phone (713-4596) but has been unable to reach, so he left a msg at pt's place of employment. jlgordon, RN DOCUMENT TYPE: Interdisciplinary Narrative Form RESULT STATUS: Final PERFORM INFORMATION: McNair, Julie (3/5/201019:54 EST) SERVICE DATE/TIME: 3/5/2010 19:54 EST Interdisciplinary Narrative Form 03/05/10 07:54 pm Performed by McNair, Julie Entered on 03/05/10 07:55 pm Inlerdisciplinary Narrative --------------------------- Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text 1950 Assumed care of pt. from J Gordon RN. Report to Peds called by J gordon. suturing at BS continues. Child Life present. ' ICtArNleir Rn ' " , DOCUMENT TYPE: Interdisciplinary Narrative Form ' ~ . Fr RESULT STATUS: Final ` . ~ , PERFORM INFORMATION: McNair, Julie (3/5/2010 20:13 EST) SERVICE DATElTIME: 3/5/2010 20:13 EST l:atw/°I`i~., ~ i~ri'a~c;l: :~/19/.~s'< .:''~':"_~^ EL t' iilt~t'd f't, t~i'.iil^r, ~~~r~rc~~l I_ PENN~TATE HERSHEY _ /~1 Mi~tan ~. Hershel l~Iedical ~ente~° Patient Name: GARLAND, TIARRA J MRN 7506936 ..._.... V .............................................~~.............................._............_........... V........................~........................; Interdisciplinary Narrative Form Interdisciplinary Narrative Form 03/05/10 08:13 pm Performed by McNair, Julie Entered on 03/05/10 08:13 pm Interdisciplinary Narrative Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Text 2010 Suturing complete. Mom at BS. Pt resting quietly. Awaiting tx to pads. JMcNair RN DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Interdisciplinary Narrative Form Final Hammer, Sarah B (3/5/2010 20:34 EST) 3/5/2010 20:34 EST Interdisciplinary Nanative Form 03/05/10 08:34 pm Performed by Hammer, Sarah B Entered on 03/05!10 08:34 pm Interdisciplinary Narrative Interdisciplinary Narrative Discipline Nursing Interdisciplinary Narrative Texi Pt transported to admission bed. !~ri;1tC'd I~?,<: ,'.hi~cr~,+" ~'!'1•,.`':rl ~.. ~ENN~TATE HERSHEh Milton S. Hershey Medical tenter Patient Name: GARLAND, TIARRA J MRN 7506936 ....................................~__._..._.._....._._......_......._......._..................................~........~..._.....~..........._............~....~.w...._................................._.................. Med Dosing Weight Form DOCUMENT TYPE: Med Dosing Weight Form RESULT STATUS: Final PERFORM INFORMATION: Gyorfi, Justin R (3/5/201019:02 EST) SERVICE DATE/TIME: 3/5/2010 19:02 EST Med Dosing Weigh Form 03/05/10 07:02 pm Performed by Gyorfi, Justin R Entered on 03/05/10 07:02 pm Med Dosing Weight ----------------- Weight 15.000 kg ~~ I'~rlilt~~ F_'V: `='-ti'9C-?~', C;E'?~~~.l I_ PENN~TATE HERSHEY Milton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J MRN 7506936 .......•.....v ................~.......___.._......~...........~........._... ................................_.,..~..........~.............._.~,......~.~....,.....................................~......................... Neurological Assessment Form DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Neurological Assessment Form 03/05/10 09:30 pm Performed by Yuhas, Erika Entered on 03/05/1011:25 pm Peds Coma Neurological Assessment Form Final Yuhas, Erika (3/5;2010 21:30 ESTj 3/5/2010 21:30 EST Eye Opening Response Peds Coma Spontaneously Best Motor Response Peds Coma Obeys Best Verbal Response Peds Coma Appropriate words/phrases Drug Effect No - Patient Tube No Pediatric Coma Score 15 Neuro Detailed Pupil Size, Left Pupil Size, Right Pupil Assessmenl Grid Pupil, Left Pupil Description Pupil Reaction Pupil, Right Pupil Description Pupil Reaction 5.0 5.0 Regular, Dilated Brisk Regular, Dilated Brisk Comment: dilated by MD Facial Symmetry Symmetric Characteristics of Speech Clear Level of Consciousness Alert, Oriented Neurological Strength LUE Neurological Strength LUE: Normal Neurological Strength RUE: Normal Neurological Strength LLE: Normal ~ ; Neurological Strength RLE: Normal ' Neurological. Tone RLE Neurological Tone LUE: Normal ~. 4 4 Neurological Tone RUE: Normal r , • Neurological Tone LLE: Normal , Neurological Tone RLE: Normal ~ ~ ~ , Neurological Sensation Grid Neurological Sensation LUE: Intact • Neurological Sensation RUE: Intact • Neurological Sensation LLE: Intact ' ' DatelTime Printed: 5/19!2010 07:24 EDT ^~~-~ ~-•+. ,,F ~ ~? Printed By: Shiner, Crystal L PE~VNSTAI E HERSHEY Milton S. Hershey N~ei~;~1 ~'~~~~~~ Patient Name: GARLAND, TIARRA J MRN 50G93u ......w.V, ..................,........_..._...._a..._...._.....v.._................................................~......,...V.......,,..............~.....~...~..w.~~.........~.............~....~.~................., ,Neurological Assessment Form Neurological Sensation RLE: Intact DOCUMENT TYPE: Neurological Assessment Form RESULT STATUS: Final PERFORM INFORMATION: Yuhas, Erika (3/61201000:00 EST} SERVICE DATE/TIME: 3/6/2010 00:00 EST Neurological Assessment Form 03/06/10 00:00 am Performed by Yuhas, Erika Entered on 03/06/1000:46 am Glasgow Coma Drug Effect No Patient Tube No Peds Coma Eye Opening Response Peds Coma Spontaneously Best Motor Response Peds Coma Obeys Best Verbal Response Peds Coma Appropriate words/phrases Drug Effect No Patient Tube No Pediatric Coma Score 15 DOCUMENT TYPE: Neurological Assessment Form RESULT STATUS: Final PERFORM INFORMATION: Yuhas, Erika (3/6;2010 02:30 EST} SERVICE DATE/TIME: 3/6/2010 02:30 EST Neurological Assessment Form 03/06/10 02:30 am Performed by Yuhas, Erika Entered on 03/06/1003:46 am Glasgow Coma Drug Effect No Patient Tube No Peds Coma ' , , ' Eye Opening Response Peds Coma Spontaneously ~ 4 ~ , , ' Best Motor Response Peds Coma Obeys Best Verbal Response Peds Coma Appropriate words/phrases ~ ' Drug Effect No ' ' ' DateRime Printed: a/19/201~} !?7:?4 EDT ~ . ~ • -,., Printed By: Shiner, Crystal I_ PENI~STATE HERSHEY /~1 Milton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J i=%i1=1N 750GJ:.~G .................~...._..___......_._...~......._.__..................~.~__._ ......_._..._._.._._..........._..~_.~..._..~........~w.~...._.......,............~.........._._.~...~......,..V......~,._._............ Neurological Assessment Form Patient Tube No Pediatric Coma Score 15 DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Neurological Assessment Form Final Yuhas, Erika {3/6/2010 07:30 EST) 3/6/2010 07:30 EST Neurological Assessment Form 03/06/10 07:30 am Performed by Yuhas, Erika Entered on 03/06/10 07:37 am Glasgow Coma Drug Effect No Patient Tube No Neuro Detailed -------------- Pupil Size, Left 6.5 Pupil Size, Right 6.5 Pupil Assessment Grid Pupil; Left Pupil Description Regular, Dilated Pupil Reaction Brisk Pupil; Right Pupil Description Regular, Dilated Pupil Reaction Brisk Facial Symmetry Symmetric Characteristics of Speech Clear Level of Consciousness Alert, Oriented Neurological Strength LUE Neurological Strength LUE: Normal Neurological Strength RUE; Normal Neurological Strength LLE: Normal Neurological Strength RLE: Normal Neurological Tone RLE Neurological Tone LUE: Normal Neurological Tone RUE: Normal Neurological Tone LLE: Normal Neurological Tone RLE: Normal Neurological Sensation Grid Neurological Sensation LUE: Intact Neurological Sensation RUE: Intact Neurological Sensation LLE: Intact F „~, b F) ~ _1~ A -`.5n (l:1C'' rllkc _. ri-i~1:~;,i ~' _, `.1r :G~r S_L.,i"~. Printed By: Shiner, Crystal I_ PENN~TAI~E HERSHE~~' ~1 Milton 5. H~~.rsl~~~~ 1! ~~,r1 ~,-~ ~,~ ~"'~! d.r~ , Patient Name: GARLAND, TIARRA J MRN 7506936 ...............,......_....~_ ...............................~..w...._~.v..V.....~........,.....,............,.....~....~............_.....~.........~.....................; Neurological Assessment Form Neurological Sensation RLE: Intact DOCUMENT TYPE: Neurological Assessment Form RESULT STATUS: Final PERFORM INFORMATION: Smith, Barbara A (3/6/201 0 1 2:15 EST SERVICE DATE/TIME: 3/6/2010 12:15 EST Neurological Assessment Form 03/06/1012:15 pm Performed by Smith, Barbara A Entered on 03/06/10 01:44 pm Glasgow Coma Eye Opening Response Spontaneously Best Verbal Response Oriented Best Motor Response Obeys simple commands Drug Effect No Patient Tube No Glasgow Coma Score 15 Peds Coma Eye Opening Response Peds Coma Spontaneously Best Motor Response Peds Coma Obeys Best Verbal Response Peds Coma Appropriate words/phrases Drug Effect No Patient Tube No Pediatric Coma Score 15 Neuro Detailed Pupil Assessment Grid Pupil; Left Pupil Description Drug Induced Dilation Pupil; Right Pupil Description Drug Induced Dilation ~ ~ ~ ' Facial Symmetry Symmetric Characteristics of Speech Clear Neurological Strength LUE ~ ' Neurological Strength LUE: 4/5 Neurological Strength RUE: Normal ~ ~ ' Neurological Strength LLE: Normal Neurological Strength RLE: Normal Neurological Tone RLE Neurological Tone LUE: Normal Neurological Tone RUE: Normal DatelTime Pri~~ted: 5/19/2.010 07:24 E[~T ~~' l~rintec! E~~~: ~hinc~r, C:,rystal L PENN~TATE HERSHEY ~1 M~tan S. ~Iershey Medical Center Patient Name: GARLAND, TIARRA J MRN 7506936 ica! Assessment Form Neurological Tone LLE: Normal Neurological Tone RLE: Normal Neurological Sensory Perception No impairment Swallowing Difficulty None Neurological Symptoms None Gail Steady 11at~/ 1 ~m~ Pr~~¢~iE,l: ~~~.,, 4,rnn.q ; ._ e•... . r~-:. ,.'~ .. ~. '. y I~rir~tcr~t Per: Shiner, Crystal I_ I~ENN~TATE HERSHEY Milton S. Hershey Medical Cent Patient Name: GARLAND, TIARRA J MRN x506936 _.-...._~~~ .................................................V.,......._.,..__....................................,V......,..,.._.......~V....._..~ Nursing iV Assessment Form DOCUMENT TYPE: Nursing IV Assessment Form RESULT STATUS: Final PERFORM INFORMATION: Smith, Barbara A (3/6/201 0 1 2:20 EST} SERVICE DATE/TIME: 3/6/2010 12:20 EST Nursing IV Assessment Form 03/06/1012:20 pm Performed by Smith, Barbara A Entered on 03/06/10 12:25 pm Peripheral IV Peripheral IV Activity Peripheral IV Site IV Site Condition InfiRration Score Phlebitis Score IV Flow/Patency IV Dressing/Activity Discontinue Left No complications 0 0 No complications Band-Aid Date/Time Printed: 5/1 9/201 0 07:2~~ fir;,°:" Printed By: Shiner, Crystal L ,~,,. <<,, ...,, .: . P"ENI~S~A~rE HERSHEY i~to~ ~. Hershey Patient Name: Gl',RLAND, TIARRA J MRN 7506936 .....~...~ .........................................................,.........................................~__........_~.._..._......~.....w.._......_..~~.......V.............~........,......,.....................` ,. Pain Response Form DOCUMENT TYPE: Pain Response Form RESULT STATUS: Final PERFORM INFORMATION: Yuhas, Erika (3/5;2010 23:05 EST) SERVICE DATE/TIME: 3/5/2010 23:05 EST Pain Response Form 03/05/1011:05 pm Performed by Yuhas, Erika Entered on 03/05/1011:05 pm Pain Response Pain Intensity Response Patient sleeping ~~.~l1"ir~:• . , Printed 6y: `''~iner, ~~~s~.~~l !. ,~ PENN~TATE HERSHEY /~.1 Milton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J MRN 7506936 ...~_______________~~._..__.._~__._~~__.__..___.~~_~.~.Pediatric Admission Assessment Form ~~~~~~__..___..__..__...__._........_..._.__..~._._._.____... DOCUMENT TYPE: Pediatric Admission Assessment Form RESULT STATUS: Final PERFORM fNFORMATION: Becker, Sarah (3/5/2010 22:13 EST) SERVICE DATE/TIME: 3/5/2010 22:13 EST Pediatric Admission Assessment Form 03!05/1010:13 pm Performed by Becker, Sarah Entered on 03/05/10 10:14 pm Allergy Allergy Reaction 1. N KA Skin Assessment on Arrival -------------------------- Skin Abnormality/Location Grid 1. Skin Abnormality None Pressure Ulcer Yes No No Pediatric Skin Risk Score Peds Mobility No limitations Peds Activity No limitationslage appropriate Peds Sensory Perception No impairment Moisture Braden! Rarely moist Peds Friction and Shear No apparent problem Peds Nutrition Excellent Peds tissue perfusion oxygenation Excellent Peds Braden Score 28 r f r i V natr:/Time {'rin°~c.i: !'/19/a~1~~ ^7:''". FAT {'rintad Lay: ::shiner, Giystal L L C 4 1 ~~~~~~~~~ ~~~~I~-~~V /~1 Milton 5. Hershey ~edieal Center Patient Name: GARLAND, TIARRA J MRN 7506936 ........w.~......w ..............~_~.~__............,.,....v..._... ~~..:.,...................................~.......~_...~................_....~......._......v............_._.....~.............._............... Pediatric Admission Assessment it Form DOCUMENT TYPE: Pediatric Admission Assessment II Form RESULT STATUS: Final PERFORM INFORMATION: Yuhas, Erika (3/5!2010 21:30 EST) SERVICE DATE/TIME: 3/5/2010 21:30 EST Pediatric Admission Assessment II Form 03/05/10 09:30 pm Performed by Yuhas, Erika Entered on 03/05/10 11:24 pm Admission History ----------------- Admitted From Emergency Department Transport Mode Litter Accompanied by Names Mom--Tiffany Isolation Precautions None . Chief Complaint MVC Patient offered hosp. safe for valuables Refused Clinical HeigM/Weight ---------------------- Patient Weigh 15.000 kg Weight 15.000 kg Weight Method Estimated Allergy Allergy 1. NKA Reaction Primary Pain Adequate Pain Control Primary No Pain Pain Intensity 0 Current Medications No Historical Medications None Peds Medical Hx I Peds Medical HX I HEENT Denies: Patient Peds Medical HX I Gastrointestinal Grid Denies: Patient Peds Medical HX I Cardiovascular Denies: Patient Peds Medical HX I Gent Grid ~.,.~. </Tirne Prlnt~c:;: :. .. ....: ~ . .~ l~riisted Bv: `>;is~~v;, c~n~st~l t_ PENNSTATE HERSHEY N~ilton 5. Hershey Patient Name: GARLAND, TIARRA J Mt~ld X506936 __..~..._w...._..----~~ .................v.,.~._.....~....._......._.......~...._................................~._.~~...,.....~..,..~....._.......~......~...~,.~......w........._....._........_....................., Pediatric Admission Assessment 11 Form Denies: Patient Peds Medical HX I Respiratory Denies: Patient admitted with urinary catheter in place No Peds Medical HX I Musc Grid Denies: Patient Peds Medical Hx II ------------------- Denies Endocrine History Ped Denies: Patient Peds Medical HX II Hemat Grid Denies: Patient Peds Medical HX I I Neuro Grid Denies: Patient Peds Medical HX II Behavioral Grid Denies: Patient "NOT VALUED" Denies: Patient Peds Medical HX II Onc Grid Denies: Patient Peds Medical Hx III Injuries Peds Health History None Infectious Disease Exposure Last 4 weeks No Exposure to head lice in past two weeks No Medical Devices None Implanted Metal No Immunizations Current Yes Psychosocial Domestic Concerns None Adult Staying with Child ai Hospital Mom Emotional Support Available Yes Financial Concems Re Hospital/Disch No Psychiatric Admission No Chronic/Terminal Illness Freq Visits No During last month felt down or depressed NIA During last month felt little interest N/A Nutrition ~ ~ ~ ` ` ` Home Diet Regular ~ ~ ~ • Peds High Risk Nutrition . , , Persistent N/V/D in Infant (0-12mo) >1 week: No ` , _ , , Date/Time Printed: 5/19/?_010 0?:'?~?• ~f.?~' - • ' €~rinted Pd~: ~I-incr, Crystal I_ PENN~TATE HERSHEY 1~1 N~ton S . ~~~~~~~ ~; .. _ _ _. Patient Name: GARLAND, TIARRA J MRN 7506936 _...~ .............................................~..~.._......._...,...~.._..................................._..........._.,.,..~.~~..........,....~......~...~.................~..w.,......~..............._..........; Pediatric Admission Assessment 11 Form Persistent N/V/D in Child {> 1 yr) > 2 weeks: No Tube Feedings Assessment: No Total Parenteral Nutrition (TPN): No High Risk Dx: Shod Gut, FTT, Vented Pts: No High Risk Dx: Cystic Fibrosis, Malnutrition: No Difficulty Swallowing or Chewing: No Modified Diet (Other than Regular Diet or Infant Formula): No Weight Change No Education Educational Needs Assessed Yes Barriers to Learning None evident Learning Preferences Verbal Explanation, Printed Instructions I~~^4e/Ti~"~ , n~-o~...,a; c0-~n~•,ny n ,~•o~. rr,~- Printed Py: Shinor, Cr%~stal l.. ~~ ~ ,» ,,., ',~., ~•,,~.,, r„~ „r 7 ,,~ PENN~TATE HEfiSHEY /~.1 M~.ton S. Hershey Me,~cal Center Patient Name: GARLAND, TIARRA J MRN 7506936 ...~.....~ .............~.._.~___.....~._...~..~_..~...~_.......~.~....__..........................~~~_...,......~_....~....,.....~.........V.....`......~..~.~~........~_.....~...........................~ ,... .. Pediai'ric Ongoing Assessment Form DOCUMENT TYPE: Pediatric Ongoing Assessment Form RESULT STATUS: Modified PERFORM INFORMATION: Yuhas, Erika (3/6;2010 00:01 EST) SERVICE DATE/TIME: 3/6/2010 00:01 EST Pediatric Ongoing Assessment Form 03/06/10 00:01 am Performed by Yuhas, Erika Entered on 03/0611000:51 am Updated on 03/06/10 00:52 am by Yuhas, Erika Review Neurological Document Assessment Document assessment Eye, Ear, Nose and Throat Within Defined WDL's Cardiovascular Within Defined Limits WDL's Respiratory Within Defined Limits WDL's Gastrointestinal Within Defined Limits WDL's Genitourinary Within Defined Limits WDL's Musculoskeletal Within Defined Limits In Error Musculoskeletal Document Assessment Document assessment Integumentary Document Assessment Document assessment Reproductive Within Defined Limits WDL's Parent Involvement W/in Defined Limits WDL's IV Present Present Surgical Tubes/Drains Present Presets Primary Pain Adequate Pain Control Primary No Pain Pain Intensity 0 Neuro Detailed -------------- Pupil Size, Left 5.5 ~ , ` Pupil Size, Right 5.5 ' Pupil Assessment Grid ' Pupil. Left r ~, Pupil Description Regular, Dilated , Pupil Reaction Brisk , , ' ; Pupil. Right Pupil Description Regular, Dilated Pupil Reaction Brisk Facial Symmetry Symmetric , ' ~ ~ , Characteristics of Speech Clear ' DatelTimeF'ric34~r~: ~:I'ii'I2(1`ift (I7:?~ rnT r,~ ., ,,, Printed Ry: Shiner, Crystal !_ PENN~TATE HERSHEY /~.1 Miltan S. Hershel M~dic~l '~~~~;~~ Patient Name: GARLAND, TIARRA J l~lt~l I`i0ci93~ _.._V....._..,,, .......................................................................................................~..k..................~......~..~,........_........._....._................_..............................; Pediafric Ongoing Assessmenf Form Neurological Strength Grid Neurological Strength LUE: Normal Neurological°Strength RUE: Normal Neurological Strength LLE: Normal Neurological Strength RLE: Normal Neurological Tone Grid Neurological Tone LUE: Normal Neurological Tone RUE: Normal Neurological Tone LLE: Normal Neurological Tone RLE: Normal Neurological Sensation Grid Neurological Sensation LUE: Intact Neurological Sensation RUE: Intact Neurological Sensation LLE: Intact Neurological Sensation RLE: Intact Neurological Swallowing Difficulty None Extremity Movement Equal Gait Steady CV Detailed Nail Bed Color Pink Clubbing Present No Capillary Refill < 2 seconds CV Detailed Pulses Grid Radial Pulse, Left: 2+ Normal Radial Pulse, Righi: 2+ Normal CV Detailed Extremity Temp Grid Arm, Left: Warm Arm, Right: Warm • Foot, Left: Warm Foot, Right: Warm Hand, Left: Warm Hand, Right: Warm Leg, Left: Warm Leg, Right: Warm Torso: Warm Respiratory Respirations Unlabored Respiratory Pattern Regular Cough None ~.<<<. Printed 13;x• `'B~i~-r:~, ~' , ~•I ~ . PENN~TATE HE~51~~~~• 111VIiltor~ Sc ~ ~"= ~:~ • ~, ~~~~~,~ _ _. Patient I~~.~:F::.-;f",N~3L/'~€JD, t~l; ~,~~~r:'~ J Pediatric Ongoing Assessment Form GI Detailed Abdomen Palpation Non-Distended, Non-Tender, Soft Bowel Sounds Grid LUQ: Present RUQ: Present LLQ: Present RL~: Present Musculoskeletal Spinal Precautions Cervical spine Skin Assessment on Arrival -------------------------- Skin Turgor Normal Mucous Membrane Description Moist, Pink Skin Abnormality/Location Grid 1. Skin Abnormality Location Other: Above Left Eye Skin Abnormality Other: Sutured Laceration Pressure Ulcer Yes No No 1 ncision/Wou nd/Drain/Tubes - ------ ------------------- Incision/VVound Care Grid 1. Incision/Wound Type Laceration Incision/Wound Location Eye, Left, Other: Above Incision/Wound Description Sutured Incision/Wound Color Pink IncisioriMlound Drainage None Peripheral IV Peripheral IV Activity Assessment Peripheral IV Site Left, Antecubiial IV Site Condition No complications Infiltration Score 0 Phlebitis Score 0 Pediatric Skin Risk Score Peds Mobility No limitations Peds Activity No limitations/age appropriate Peds Sensory Perception No impairment Moisture Bradenl Rarely moist Peds Friction and Shear No apparent problem Peds Nutrition Excellent I7ate/Timel'ri~-~teci: a/i9/20~i007 :'?^ `T`P:•'~ PrinteJ ~;/: 51"iinF,r, ~rl~s•iai !. I\.~RN 750G93f~ ,. _ ~, PENNSTAT~ HERSHEY /~1 MHton S. Hershey l~I~d~~~l ~~~¢~;~ Patient Name: GARLAND, TIARRA J ivil~i~i I~UG9;; ._~_.._...~ .................~_.......~.w....~..._......__...._....~._._.........................................~_._......~.~...~~......_.~.~.a..........._..._......._.........~.... -Pediatric Ongoing Assessment Form Peds tissue perfusion oxygenation Excellent Peds Braden Score 28 Transport/Order Detail Section ------------------------------ Transport Mode Litter Isolation Precautions None Monitor No Do Not List No Transport Accompanied By None, Parent Respiratory Needs None E'rifltr:~J Eau: ~~~inn~-, rry54al I... PENN~TATE H~.~SHEY M~ton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J ~~%~i=i~l iipG9 ~0 ,~.~ ._~...~ ...............w......._.~..~..~~......_..._..~~..a..~..._w...................................~..~..µ.~......_.~.....~....~......v.,...~.....,..._......, V......_............_..~.....,..............._., Peds Skin Assessment on Arrivai Form DOCUMENT TYPE: Peds Skin Assessment on Arrival Form RESULT STATUS: Final PERFORM INFORMATION: Yuhas, Erika (3!5;2010 21:00 EST) SERVICE DATE/TIME: 3/5/2010 21:00 EST Peds Skin Assessment on Arrival Form 03/05/10 09:00 pm Performed by Yuhas, Erika Entered on 03/05/1011:22 pm Skin Assessment on Arrival Skin Turgor Mucous Membrane Description Skin Abnormality/Location Grid 1. Skin Abnormality Location Skin Abnormality Pressure Ulcer Yes No Normal Other: Above Left Eye Other: Laceration No ' Moist, Pink Pediatric Skin Risk Score Peds Mobility No limitations Peds Activity No limitations/age appropriate Peds Sensory Perception No impairment Moisture Braden! Rarely moist Peds Friction and Shear No apparent problem Peds Nutrition Excellent Peds tissue perfusion oxygenation Excellent Peds Braden Score 28 ;. ` f !- Dateri'ime Printed: 5liQ/?.(11~ ~7:?.~.F,nT "='^~~ ~~ r;~ ` "' c'ri;~iea lSy: :31-~6ss~:r, t::~yst~i I_ '~'~!~'.~.1~~'~TE HERSHEY Mi~.ton S. Hershey ~~~ gal tenter Patient Name:4GANLANU, i (/~fIFiA J fUil'1iJ ~G6J~i .~....~ ............................................ ........Physician, Discharge Insfructions, Form,. ,.......,..,.............................,...,,,.,,.,,..,,,. DOCUMENT TYPE: Physician Discharge Instructions Form RESULT STATUS: Final PERFORM INFORMATION: Gyorfi, Justin R (3/6/201 0 1 1:34 EST) SERVICE DATE/TIME: 3/6/2010 11:34 EST Physician Discharge Instructions Form 03/06/1011:34 am Performed by Gyorfi, Justin R Entered on 03/06/10 11:53 am Patient Discharge Instructions - HMC Discharge Diagnosis Principle Left clavicle fracture Forehead laceration Other Discharge Diagnoses None Procedures None Discharge Care Instructions 1. Please follow up with your Pediatrician over the next week. You will need to make this appointment. 2. Please follow up with Pediatric Surgery at the time assigned (see below) 3. Please follow up with Pediatric orthopedics as instructed. You will be contacted for this appointment. 4. Please follow up with Pediatric ENT as instructed. You will be contacted for this appointment. 5. Pain Control: Please use over-the- counter Motrin and Tylenol for pain control as discussed. Diet Guidelines Regular as tolerated Activity Guidelines No weightbearing on the left armishoulder. Call Your Doctor: Please call the hospital operator at 717-531-8521 and ask for the pediatric surgery resident on call if your child develops fevers above 102, is unable to tolerate feeds, turns blue, has increasing difficulty breathing, or other worsening or ~ ~ r ' ~ ' concerning symptoms. , For non-urgent issues or questions, you can contact the pediatric surgery ~ ` ~ `~ , department at 717-531-8342. Other Instructions Follow-up appointment with Pediatric Surgery in 3-4 weeks. You will be ~ , called with adate/time for followup 4 1-~Ci~1i :,I L~,J: ~I'1int~f', !., tS ~/S~rl I_ PENN~~TATE HERSHEY -- 1~1 Milton S. Hershey Medical tenter Patient Name: GARLAND, TIARRA J Physician Discharge instructions Form MRN 7506938 appointment. If you have not heard back in 3-5 business days, you may call 531-8342 Follow Up Apppointments Follow up Gare has been addressed Physician Discharge Summary HMG Brief History The patient presents wish major trauma and restrained passenger behind driver second row involved in unknown speed T bone type MVC with 8 inches of intrusion -Unresponsive for about 1 minute upon arrival of EMS -noted to have laceration of left forehead and left clavicle fracture. CT scan ruled out intracranial injury. Include Hospital Course No Hospital Course Pt was admitted to the pediatric surgery team. ENT was consulted to suture up the laceration. Opthamology was consulted and did an examination to rule out retained glass in her eyes. Orthopedics treated her for her left clavicle fracture. On the next day, 3/6/10, she was tolerating a regular diet, pain was controlled, and she had follow-up arrangements with her subspecialty consults. She was stable for and discharged home with these follow-up appointments and a script for Keflex per ENT. Exam On Discharge Gen: Awake, Alert, NAD HEENT: Laceration sutured, c/d/i. PERRLA. Mucous membranes moist. CN intact. Card: RRR, No r/mlg Pulm: CTAB. No w/Nr Abd: Soft, NT, ND. ,. ~ ~' Ext: Patient moves all extremities spontaneously. Dictation # 398777 ' . , ' nate/Tirn~: 6'ri~iF-.:i: 5/19/?_~J1f~ ~7:?'! r^•~- P""" 71 ^~ ~ n' I~E~inted By: Shiner, Crysi~l L PE~i~~TATE HERSHEY Milton 5. Hershey Medical Center Patient Name: GARLAND, TIARRA J ~... ~"""~"~"_`~~_„"_,___~_`~"_•„_"„ ` ,_„m„Physician, Discharge, Instructions, Form ,F,~ DOCUMENT TYPE: Physician Discharge Instructions Form RESULT STATUS: Modified PERFORM INFORMATION: McIntyre, James S (3/6/201 0 1 1:57 EST) SERVICE DATE/TIME: 3!6/2010 11:57 EST Physician Discharge Instructions Form 03106/1 0 1 1:57 am Performed by Gyorfi, Justin R Entered on 03/06/1011:58 am Updated on 03!06/10 01:02 pm by McIntyre, James S Patient Discharge Instructions - HMC Discharge Diagnosis Principle Left clavicle fracture Forehead laceration Other Discharge Diagnoses None Procedures None Medication Review Complete Discharge Medication Reconciliation Completed Discharge Care Instructions 1. Please follow up with your Pediatrician over the next week. You will need to make this appointment. 2. Please follow up with Pediatric Surgery at the time assigned (see below) ' 3. Please follow up with Pediatric orthopedics as instructed. You will be contacted for this appointment. 4. Please follow up with Pediatric ENT as instructed. You will be contacted for this appointment. 5. Pain Control: Please use over-the- counter Motrin and Tylenol for pain control as discussed.. 6. Please have sutures removed in 5 days by your pediatrician. 7. Ok to shower or wash wound with ' soap and water. Do not soak in bath ` or swim for 7 days. (modified) ~ ~ ~ `, Diet Guidelines Regular as tolerated ~ ~ , Activity Guidelines . No weightbearing. on the left ~. ~ ~+ Y N arm/shoulder. ~ . ' , Call Your Doctor: Please call the hospital operator at , 717-531-8521 and ask for the , , , pediatric surgery resident on call if Date/Tim~ Pri^~t~rl: .<< F/1 c/ar~1n n7:?~. ~[??- ,~.,,,,, -,, „~ ,,.., Printed i3y: Sl~irivr, C~rys•ial PENI~~TATE HERSHEY /~~1 Milton S. Hershey Me~.lcal Center Patient Name: GARLAND, TIARRA J Discharge Instructions Form your child develops fevers above 102, is unablQ to tolerate feeds, turns blue, has increasing difficulty breathing, or other worsening or concerning symptoms. For non-urgent issues or questions, you can contact the pediatric surgery department at 717-531-8342. Other Instructions Follow-up appointment with Pediatric Surgery in 3-4 weeks. You will be called with a dateltime for followup appointment. If you have not heard back in 3-5 business days, you may call 531-8342 Follow Up Apppointments Follow up Care has been addressed Physician Discharge Summary HMC ---- --------------------------- Brief History The patient presents with major trauma and restrained passenger behind driver second row involved in unknown speed T-bone type MVC with 8 inches of intrusion -Unresponsive for about 1 minute upon arrival of EMS -noted to have laceration of left forehead and left clavicle fracture. CT scan ruled out intracranial injury. Include Hospital Course No Hospital Course Pt was admitted to the pediatric surgery seam. ENT was consulted to suture up the laceration. Opthamology was consulted and did an examination to rule out retained glass in her eyes. Orthopedics treated her for her left clavicle fracture. On the next day, 3/6/10, she was tolerating a regular diet, pain was controlled, and she had follow-up arrangements with her subspecialty ~ ~ , consults. She was stable for and discharged home with these follow-up appointments and a script for Keflex per ENT. ` ' ' Exam On Discharge Gen: Awake, Alert, NAD ' ' HEENT: Laceration sutured, c/d~. ~ ~ ~ < PERRLA. Mucous membranes moist. CN <<, ' , .,., , - . ,.~ Date~fin~e I'rii-~tcd: 5/19/2010 07:?~ F1~°T° ~ ,~,_. I'rinterJ By: ShinEr, Crystal L PENNSTATE HERSHEY ~1 Mi~.ton S .Hershey ~'Iedica~ Center Patient Name: GARLAND, TlARRA J MRN 7506936 _...._...~_.._._.~____________________~......w......._......__.Physician Discharge Insfrucfions Form ...~_.._...__._....._......_..._.............~...._..._.._.... intact. Card: RRR, No r!m/g Pulm: CTAB. Now/r/r Abd: Soft, NT, ND. Ext: Patient moves ail extremities spontaneously. Dictation # 398777 Printed By: Shiner, Cr}rst~al !_ PENN. ~~~ ~. t-~l`_t-~~t~% ~~ Milton 5. ~iershey Patient Name: GARLAND, TI!`:if--tl1 .! MRN 7506936 .~~..._._.~.w .............~........~......~......._._~__--------------- Quality Measures on Arrival Form DOCUMENT TYPE: Quality Measures on Arrival Form RESULT STATUS: Final PERFORM INFORMATION: Gyor6, Justin R (3/5/201 0 1 9:01 EST) SERVICE DATE/TIME: 3/5/2010 19:01 EST Quality Measures on Arrival Form 03/05/10 07:01 pm Performed by Gyorfi, Justin R Entered on 03/05/10 07:01 pm Quality Measures on Arrrival ---------------------------- Medication Reconciliation Status Medication Reconciled to the best of ability with limited information Urinary Tract Infection Patient does NOT have a Catheter Related Urinary Tract Infection Line Infection Patient does NOT have an existing vascular access catheter (line) Decubiius (pressure) Ulcer Patient does NOT have a Decubitus Ulcer VTE Risk Score 0 to 1 point -Low Risk fJatell'im~ Pr?~fc~'; r/1~?/?010 07:2.4 Fi)T Printed ey: Shiner, Crystal L P~~INSTATE HE~Si~~.~ ,~;.. , ~1 Mi~fion S o ~~ . ~ p ~~ ~>11~~'~'r;~'' ,::' Patient Name: GARLAND, TIARRA J MRN 7503936 .............................~.__..._..._.._._.~..~...._. Respiratory Therapy Time/Equipment Form"~""~~~~"~~~~~~µ~~~"„~`~"~"~""~""` DOCUMENT TYPE: Respiratory Therapy Time/Equipment Form RESULT STATUS: Final PERFORM INFORMATION: Thomas, Kris D (315/201 0 1 8:46 EST} SERVICE DATE/TIME: 3/5/2010 18:46 EST Respiratory Therapy Time/Equipment Form 03/05/1006:46 pm Performed by Thomas, Kris D Entered on 03/05/1006:46 pm RT Time/Equipmenl ----------------- Patient Procedure Trauma RT treatment duration 10 minute E`'rif~tod By: Shiner, Crystal I_ PENIVSTATE HERSHEY /~1 Miiton S. Hershel ~e~lic~l Ce~~~~- Patient Name: GARLAND, TIARRA J MRN 7606936 Safefy Wristband Verification Form DOCUMENT TYPE: Safety Wristband Verification Form RESULT STATUS: Final PERFORM INFORMATION: Yuhas, Erika {3/6;2010 00:01 EST) SERVICE DATE/TIME: 3/6%2010 00:01 EST Safety Wristband Verification Form 03/06/10 00:01 am Performed by Yuhas, Erika Entered on 03/06/1000:46 am Safety Wristband Verification ----------------------------- Safety Wrist Band Verification Patient identification ~:^.r Printed fay: Shiner, Crystal L •`; ~.-~ - PENNSTATE HERSHEY Patient Name: C:.`:~=tLf~ND, il/~RCi,~I J M~iN 7a0693G ,......... ,,.._....~.......~._.~..........~..._.._........~...~.........,..., ....................................a.,,....~~..,............, . Spiritual Care Note Form DOCUMENT TYPE: Spiritual Care Note Form RESULT STATUS: Final PERFORM INFORMATION: Ogilvie, Peter O (3/6/201009:23 EST) SERVICE DATE/TIME: 3/6/2010 09:23 EST Spiritual Care Note Form Entered On: 03/06/2010 09:25 Performed On: 03/06/2010 09:23 by Ogilvie, Peter O Spiritual Care Note Pastoral Services Visit : Trauma Pastoral Impact Stan : Somewhat upset, anxious Length of Vtsit : 40minute Pastoral Intervention : Prayer Pastoral service Follow up : Yes Pastoral Services Comments : 3/5/10 at 18:30 hrs. Peds Trauma. MVA. 4yr old Pt was unrestrained in an infant seat. Received head contusion and cut above her eye. Pts family arrived an hour later. Follow up recommended. Peter Ogilvie, chaplain. Derrickson, Paul - 03/10/201008:35 ~ r-t,...~nni r.-,.-fin '_ Printed sy: Shiner, Crystal L_ PENN~TATE HERSI~t~r}` Milton S. ~-Iershey Nle~cal tenter Patient Name: GARLAND, TIARRA J MRN 7506936 Treatment Form DOCUMENT TYPE: Treatment Form RESULT STATUS: Final PERFORM INFORMATION: Yuhas, Erika (3/5!2010 22:45 EST) SERVICE DATE/TIME: 3/5/2010 22:45 EST Treatment Form 03/05/1010:45 pm Performed by Yuhas, Erika Entered on 03/05/1011:27 pm Activity Activity Status ADL Bathroom privileges Date/Time Printed: 5/19/2010 07:?~• FnT t'rinted Fay: Shiner, Crystal L ,., c ~ w err a e e , PENNSTATE HERSHEY Milton S. Hershey Medical tenter Patient Name: GARLAND, TIARRA J i~AFN '1506~3C~ _._..~.~_.___.~._~.w.._a._._....__~.~.w~..w....~.......~ ....................Vital Signs Form ...~.......~._..........a..._..._....~._...__._~.._~..............~....___..._..... DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Vital Signs Form Final McNair, Julie (3/5/2010 20:08 EST) 3/5/2010 20:08 EST Vital Signs Form 03/05/10 08:08 pm Performed by McNair, Julie Entered on 03/05/1008:09 pm Vital Signs Heart Rate 118 bpm Respiratory Rate 20 br/min Oxygen Therapy Room air Monitor Rhythm Sinus Systolic Blood Pressure 104 mmHg Diastolic Blood Pressure 57 mmHg BP Location # 1 Left Arm DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Vital Signs Form 03!05/10 08:49 pm Performed by Bartell, Sharon Entered on 03/05/1008:57 pm Vital Signs Temperature 37.0 DegC Temperature Route Temporal Heart Rate 120 bpm Oxygen Saturation 100 Respiratory Rate 24 br/min Systolic Blood Pressure 117 mmHg Diastolic Blood Pressure 77 mmHg BP Location # 1 Left Arm Vital Signs Form Final Bartell, Sharon (3/5/2010 20:49 EST} 3/5/2010 20:49 EST DOCUMENT TYPE: Vital Signs Form ~ ~ ' , ' RESULT STATUS: Final ; ~ ~ ,.;, ~ ` ' PERFORM INFORMATION: Bartell, Sharon (3/5/2010 23:08 EST) ~ ~ , SERVICE DATE/TIME: 3/5/2010 23:08 EST ' Vital Signs Form DatelTime Printed: 5/19/2010 07:?^ ~'`~°'" - ~ ~ ~" ' ' Printed By: Shiner, Crystal L PENN~T~ITE HE~~I-IEY MHton S. Hershey 1lrled~cal Center Patient Name: GARLAND, TIARRA J PNRN 7506936 ...,.......~ ......................................................~...~.__..._~..................................v...........y....................._.................._..................... Vita! Signs Form 03/05/10 11:08 pm Performed by Bartell, Sharon Entered on 03/06/10 00:14 am Vital Signs Temperature 36.8 DegC Temperature Route Temporal Heart Rate 111 bpm Oxygen Saturation 97 Respiratory Rate 24 br/min DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Vital Signs Form Final Bartell, Sharon (3/6/2010 04:00 EST) 3/6!2010 04:00 EST Vital Signs Form 03/06/10 04:00 am Performed by Bartell, Sharon Entered on 03/06/1005:09 am Vital Signs Temperature 36.7 DegC Temperature Route Temporal Heart Rate 108 bpm Respiratory Rate 24 br/min DOCUMENT TYPE: RESULT STATUS: PERFORM INFORMATION: SERVICE DATE/TIME: Vital Signs Form Final Lytle, Rebecca E {3/6/2010 07:45 EST) 3/6/2010 07:45 EST Vital Signs Form 03/06/10 07:45 am Performed by Lytle, Rebecca E Entered on 03/06/1008:59 am Vital Signs Temperature 37.3 DegC Temperature Route Temporal Heart Rate 120 bpm Respiratory Rate 28 br/min Systolic Blood Pressure 94 mmHg Diastolic Blood Pressure 57 mmHg !~-: ~t~~'ir -~ rS:•~~xnEti: ~'/'1 t'1/7!»fl n7:^n. t'r-T 1'rinteel Ly: ~~;~iner, urystai L ,, o ~ " rff '~,' ; ,~ r,,,_._`F., _. •. ~~ PENN~TATE HE~~~~EY /~1 Milton S. ~I~x~shey Patient Name: GARLAND, TIARRA .J ws;i~1 7:10393G .........~.~....~~.w..v._..........a._.........~.....W........~.._.~ ...............Measuremen is '.._a_............~ ~~..~...................~...........~.~........~.............. Retarded Date 3/5/2010 31512bt0 Recorded Time 21:30 EST 19:02 EST Recorded By Yuhas, Erika Gyorti,,Jusiin R Proceirture Uhits :Patient Weight kg ~ 15.000 °t __ . _._ . - Weight kg 15.00001 15.000 :Weight Method Estimated O1 ~ ' Order Comments 01: Ped Admit2 Assessment Ped Admit2 Assessment .. V 4 t Y ( ~ i DatelTim~ Pri;,t;, -~ ~ ~/~ r/^^ , ^ ,..,.,, ^ ~_~,.,_ Printed By: Shin°r, Ce~~sirzl !_ PENN~TATE HERSHEY Milton 5. Hershey Medical Center Patient Name: GARLAND, TIARRA J ~l',N 750G93G .~.~._..._.___~...____.~ .................~___._..___~__.~~.........._.................._...Vital Signs~._....__.~.~.~.._.___~.._.~~..._.~......_...........~.............~........_.._......_. Recorded Date 3l6/2b'f 0 3f6/2(?'10 ' 31512Q~Q 3/5/2010. Gecorded Time , 07:45 EST 04:00 EST 2~:E~.1ES`T 20:49 EST Recorded By Lytle; Rebecca E Bartell, Sharon ; Barbell, Sharon Bartell, Sharon Pr~re..:. > ._ lJnats :Temperature :DegC 37.3 .. 36.7 36.8 37.0 Temperature Route :: : :: , , Temporal : , _ . .. Temporal Temporal . : ~ Temporal .... .. . .Heart Rate ...... bpm. . .. . . . ..1.20 ....... .. 108 .. ... ~ 111 1.20 ::Respiratory Rate ~bdmin 28 24 24 24 systolic Blood Pressure :mmHg 94 - - 117 Diastolic Blood Pressure :mmHg 57 - - 77 6P Location # 1 - - - Left Arm :Oxygen Saturation % - - 97 ........:. 100 ................................... Recorded ,Gate ........................... 35/2010 Recorded.Time : __ _ _ 2Q:08 EST . ..................... Recorded Hy' . ................. McNair; Julie PrEicierltitra. : :: : <:: Units : : ..............: ::Heart Rate : .bpm, 11t3 ::Respiratory Rate : br/min : : 20 : . ............................................... systolic Blood Pressure ............................... . . :mmHg ........................... 104 ::Diastolic Blood Pressure : :mmHg : :: 57 ; ............................................... BP Location # 1 ............................... . . .......................... Left Arm :Oxygen Therapy Room air itAonitor Rhythm Sinus '<< i Printed 13y: Shin:ar, r^rystal I.. ,~,. <<< PENI~~TATE HERSHEY ~O~?. _, ~ ,, Patient Name: GARLAND, TIARRA J MRN 750693G _..__~..._~.._.....~__.~_________________~_..__~..~.~_.__.____..~.~.___..____.Pain Assessments...~..~._..~_._~.._.~..~.~_...~.~..~..____.~..~...a..~.~........._....... Recorded Bate 3/6/201 fl 3/5/2010 ` >~/~l2010 Recorded Time 00:01 E5T 23:05 EST 22.35 EST Recorded By Yuhas, Erika > Yuhas, Erika Yuhas'; Erika >..#~cc~ceduF~' ..: Units`. Adequate Pain Control Primary No Pain - ... _. - :Pain Scale Primary , . ? - - INorig Baker Pain Scale .Pain Intensity _ 0 _ _ ::Pain Intensity Response .:.............................................................. - :................................:...........................: Patient sleeping ~ ................................. 2 ...............................................: .E~~ Printed By: ~ ; ;a, ,~•, !~r~s,•,,: F ^. ~'ENN~ I~11 ~ H~,~~~~ Y Nrilton S. Hershey ' Medical Center Patient Name: GARLAND, TIARRA J MRN 7506936 .......w ................~_~...__....v........_.............,..,..~....a..............................................,.................-.........~.,,......~~. Routine Care Documentation Recorded`Date 3/6/2010 ''3I5~1~1. 3f5Y2010 Recorded Time 00:01 EST 22.4 SST _. 21:30`EST -Recorded By Yuhas, Erika' ;:: Yuha~, Eril{a _:. Yuhas, Erika.- ,i:P#OC$ditf2....::: URLtS r- :Safety Wrist Band Verification Patient identification O1 :Spinal Precautions .. Cervical spine .;. - - Activity Status ADL ~ - ~ ~ :Bathroom privileges : :, :Transport Mode Litter - Litter O2 :Isolation Precautions None - None O2 Do Not List No - ,< - ;:Transport Accompanied By None, Parent - - :-Respiratory Needs None - - Order Commenls 01: Safety Wristband Verification Safety Wristband Verification 02: Ped Admit2 Assessment Ped Admit2 Assessment ~~ .. << E''"'~ ,,~: DatelTim~ C'rintPr!: ~/-'^%?n1n (?7:~~ ~'nT P~~~ 85 ~f ~! ^;? i~rinted By: Shiner, Crystal L PENI~~ I~~•E E~E~iS~~~~. /~1 Milton S. Hershey 11~Iedical Center Patient Name: GARLAND, TIARRA J Mt~N i506~'3ci __..~ ...............~_____.___..__.___.._~_.__w~.__._.__________~~.....NeurologicaJ Documentafion_~_..__.~.,..~.__.~.._~._..__.._._~.~.___._...~...~_....____._.__.__ Recorded Date 3/6/2010 >::3f6l~~1D Recorded Time 12:15 EST ~ <0~~2.EST Retarded By Smith, Barbara A Y~ha~, Erika a~roce~uee: Units :Best Verbal Response ~ Oriented ~ - :Best Motor Response ; Obeys simple commands - :Glasgow Coma Score 15 - ::Eye Opening Response Spontaneously - ;Eye Opening ResponsePeds Coma ~ SpoManeously - ::Best Verbal Response Peds Coma : Appropriate words~phi-ases - ::Best Motor Response Peds Coma Obeys - :Pediatric Coma Score 15 - tVeurologicai Symptoms None - ::Facial Symmetry :...................................................................... :...............................: Symmetric ................................................... ~ Symmetric .:.......... .. .......... ;Gait ;....... ................................................................ :..................... .. . .: Steady . . ... . . - : Swallowing Difficulty .. .... . . . ............................................. ... None ............................ - ::Characteristics of Speech Clear Clear ::Level of Consciousness - :Alert, Oriented :Pupil Size, Left - 6.5 ;:Pupil Size, Right _ ................._.......... ..... __......._....- 6.5 Recorded Date 3M/2010 ::::3~ff~#}1t"1 Retarded Time 02:30 EST ~b~ I+ST Recorded By Yufias, Erika Y>:~frasi 1=riJta Procedure . Units ; ,: _... fye Opening Response Peds Coma ~ ........ . .. ..... . . . . Spontaneously - . :Best Verbal Response Peds Coma ... .. . ... .............:. : : _ ................................................ Appropriate words/phrases ......................... - ~Best Motor Response Peds Coma ~~~~ ~ ~~Obeys ~ ~ ~~ ~ ~ ~ ~ ~ ~ - ::Pediatric Coma Score 15 - Facial Symmetry .. ............ _ _ . _ - Symmetric Gait .. ........... ...Steady.. :Swallowing Difficulty - None Characteristics of Speech - Clear ::Pupil Size, Left ~ - ................ ..........5.5.......... ;Pupil Size, Right ......_..... . .. . .. ....5.5 _, . _... Recorded Date 3%6/201.E1 310~~010 -Recorded,Time 00;00 EST 2i~:30 EST - Recorded By _ Yuhas, .Erika Yuhas,'Erikd_' Ptdt1!'~ '' . ,. Units .: Eye Opening Response Peds Coma ~ Sporrtaneously Spontaneousi~s ~' ~. ;Besf~Verbal Resporse Peds Coma Appropriate words%phrases.Appropriatew~ords/phrases >Best Motor Response Peds Coma ~ ~~~ Obeys ~~~~ Obeys ~~,.~ :Pediatric Coma Score 15 15 ate ir~±,: ~-ri;,<., ~. ~ :. ! R,- Printed t3y: ~a~iner•, 1. crystal L PEN~I~TATE HERSHEY Nrilton S: Hershey Medical Cer~er Patient Name: GARLAND, TIARRA J MRN 7506936 .~~.~_v...._~ ...................~__.._~___.~._.__.._...~.~.M..._.~Neurological Documentation ~`~_`~~`~~`~~`~~~~~__a._~__......._...._.__.____._.___ Recorded Date. 3/6/2010 >: 3I~1'2010 Recorded. Time 00:00 EST 29 :30 EST Recorded By Yuhas, Erika Yufias, Erika Pr~ced~re Units ::Facial Symmetry ~ ~~~~~ ~ - ~ Symmetric : ::Characteristics of Speech - ........................ ~ Clear .. .Level of Consciousness _ - __ Alert, Oriented ::Pupil Size, Left - 5.0 Pupil Size, Right ~ - ................ .,......................5.0.......................: ~~ie/T irn~; s'rinted: 5/19/?.01!? (?7:~.n, '`'~` ~ , , , , ,,., ~ , Printe~.i B;r: Sf±is~aer, ~'~.y+strl 1.. PENNSTATE HERSHEY M~i~ton S. ~-Iex°~:~e~ Patient Narne: GARLAND, TIARRA J MRN 7506936 _.~~..~....._....~...~...._~.~..~..........~_.......~..~._...~.~....a .........................................,...~....V..,.~_.....k......._...................,....._.~.._~r....~..............V... HEENT Documentation Recorded Date 3l6/201'Q Recorded.Time 00:01 EST Recorded By Yuhas, Erika ,. _ f?racei#ure Units __ ::Eye, Ear, Nose and~Throat Within Defined WDL's 4„ ~ ~ ~~ ` ., m ' ,.~,. `~-=.tc/Z'i~<<-; i'rirrf;; _': ::~/:/:a11t~ 07:24 EDT , ~ , , !Tinted By: Shiner, Crystal !_ C~ENNSTATE HERSHEY ~1 Nrilton S. Hershey Mejdical Center Patient Name: GARLAND, TIARRA J MRN 7506936 Cardiovascular Documentation Recorded Date 3/61010 ~/5%~Q 1 E1 Recorded Time 00:0»EST 20 (:I*;~fi:.: Reenrded By; Yuhas Erika ; McNar, Juh~ Pt vicedttre Units ,. ::Monitor _ No _.:.: ;: - ... :Mail Bed Color Pink - Capillary Refill < 2 seconds : - :Cardiovascular Within Defined Limits : WDL's : : - ...................~................................................. :Monitor Rh hm .: ...............................:.......................... . - ...... - ~ S'i ri iis..... . :Radial Pulse, Lefi 2+~Nomial - ::Radial Pulse, Right : 2+ Normal ~ ..........................: - ... :Torso ....11Narm ......... ...........................: Arm, Left.........._..... ....__....._......_.. :>............_ ..............:........Warm.......;. ...._................._-.; ;Arm, Right . . _ Warm : . . .................................................. ::Foot, Left :..........................................................:. Warm ........................... - ::Foot, Right ......Warm ........: . ............................ ::Hand, left Warrn _ Hand, Right ~ Warm - ~: ................................................ ::Leg, Left . ...............................;........... ...........:.. V11a rm ...........................: - ?leg, Right _ ....................:........Warm.......:. ...........................: r f Y b M Date/Time Printed: a/19/2010 07:2•^-.~ I=1?T ,. , Pt•intact By: Shiner, Cr~rstal L. PENN~TATE HE~ZSHEY ~1 N~~It~~ ~. ~~rshey Patient Name: GARLAND, TIARRA J MRN 7506936 .................~........__....~_~..._v.....~_.....a..V......._.,._.a,............................................................~.~,.........._~_.._..w.....a..........._~.......~......._......................, Pulmonary Documentation Recorded Date 3/6/201:0 _. _. Recorded Time 00:01'--EST Recorded By Yuhas Erika; Procedure :> Units ,_ :Respiratory Pattern ~ ~ ~ Regular ;Respirations Unlabored ~~. ~r ' t (" f ~ f ~ i ~ ~ C / /~/1 PENN~TATE HERSHEY Milton S. T-Hershey Medical Center Patient Name: GARLAND, TIARRA J MRhi 'r`:~9G~30 ....._..._~.~._~~..~,......~..........~ .............w.._..~GI/GU/Reproductf~e Documentation ~.~_._~~..~.~_~...~.._____~~._.~..__~,._._„__..,., .Recorded Date ~/Gl2010 ` ::~I612f~_j Q Recorded Time 02:00 EST (hO:Q# SST Recorded ay Yuhas, Erika Yuhas, Erika ..> Procedure ....., . . Units , , Bowel Sounds LLQ ~ _ _ - . Present ::Bowel Sounds LUQ - ..... Present ::Bowel Sounds RLQ - .................................... Present ::Bowel Sounds RUQ - Present :Abdomen Palpation - ... ... .. Non-Distended, Non-Tender, Soft Emesis 1 - :Gastrointestinal Within Defined Limits .: - : > : WDL's : .......................................................................... :Genitourinary Within Defined Limits . ................................ .......................... - ................................................................. : WDL's ::Reproductive Within Defined Limits - WDL's rr ~ N Y ~i ~ ~ l f f~ate/Tirm,~ Printed: 5/18/?01Q 07:?-4 r"r±ry- ~ `~`-' ?i ~' ~ ,^ i'~inted C3y: Shiner, Crystal f_ PENNSTA~E HERSHEY Patient Name: GARLAND, TIARRA J MRN 7506936 __.......~~......_.~.__.~ .......................~.~...___.....__~~.Integumentary Documentation.~...~.___...........~........_...v._~....~_....~..~...._.__.._._._.. Recorded Date 3/612Q1fl 3161201 t) Recorded Time >~ 12:15 EST OOit3f 1<ST Recorded By Smith, Barbara A ~!ul~as, Erika gr~re ::.: Units Skin Turgor _. - Normal lWucous Membrane Description - Moist ~ Pirik . - Skirt Abnormality - Other: Sutured Lacera#ion :Sensory Perception No impairment - : Peds Mobility ......... - .............................................. No limitations ;:Peds Activity - No limitations%age appropriate :Peds Sensory Perception - No impairment :Moisture Bradenl - < Rarely moist ;Peds Friction and Shear .... - - ~ ~No ~apparerit problem ::Peds Nutrition - Excellent ::Peds tissue perfusion oxygenation - Excellent ;Peds Braden Score ___ __ ~- ~~~ ~ 28 Recorded Dafe ..3/8/2t31fl Recorded Time 22:~3'EST Recorded By Becker, Bereft - ~ ..: 'Frflcscfure:;:''' Units . Skin Abnormality . ~ ~ None ...: ...................................................................;. Peds Mobility ................................ .................................................. No limitations .........: ;Peds Activity ___ _ No limitations/a e a ro riate _.... 9. _ PP...P.. .. ::Peds Sensory Perception No impairment ;Moisture Bradenl Rarely moist ::Peds Friction and Shear No~apparent~problem ~ ~~~~~~~ Peds Nulydion Excellent ;Peds tissue perfusion oxygenation Excellent ::Peds Braden Score 28 -Recorded Date . >' 3/5/2p10 .. .. <3/5/2010 Recorded Ttma 21:OD EST 18:14 EST Recorded By Yuhas, ,Erika Yuhas, Erika ,. <..~rocel~urs ,: _ Units .. .: ; :Skin Turgor of Normal ..., ,. .... - , :Mucous Membrane Description Moist, Pink O1 - :Skin Abnormality _ - .. ~ .. ............Other: Laceration O1 .........~...3ee 13~lowr~ oz ` .. .: ,.:... ... .._ Sensory~Perception . ,.,:.., . .. ...... -., .,_ ....... ....... _... See elow'''Oe ACtlVlty .........................._ .................. ............. ;..., ., ., , .~ .........T9'JZ~~ '; , See B@low ' ~ . ;Nuir~ion ., -.... _. _ ... , - . . ~ S e~Belowraoz ' Moisture ...,,._ . ..,,,,.. .,., ... .:. -.. See Below TS Oz :Mobility ~ - See BelowTe°,z` Date/Time Printerl: 5/19/2(11 s1 !' ;":^.,' c:-;•° ,.,. ~ . -, Printed By: Shiner, Crystal L PENN~TATE HERSHEY /~1 Milton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J MRN 7506936 ....~......_....~...~ ..........................~.........v.........~....._...............................~,.........~....,.._...~a........V..~......_..,..~..~._.....~.~.~................-._.....__........_......... Integumentary Documentation Recorded dafe ....... . 375/2010 `' 3/5/2010 Recorded Time 21:00 EST 18:14 EST Recorded By Yuhas Erika Yuhas, Erika Fracest~te . `. Units ,.. Friction and Shear _ _ _ ...... . __ _.:: _ _ <; . .::::..:. :..:_<:_ T~o2 See Below Peds Mobility _ No limitations O1 - _ _.. _ Peds Activity ~ No limitations/age appropriaieO1_ ___ Peds Sensory Perception No impairment °t ............... ~ ~ ~ ~ ~ - :Moisture Bradenl ~ . _ Rarely moist 01 - - Peds Fnction and Shear ................ - No apparent problem O1 - ............. Peds Nuirition : ......................................off................ Excellent - Peds tissue perfusion oxygenation .. _ _ _ .... Excellent O1 . __.._.. _ ._..... , ...,.. _ .. _,. Peds Braden~Score.::. :_....: . ........................................................................................................ ,., ,...,... 2801...... .. .._. __ .... ................................................... : : Textual Results ............ ................................. T1: 3/5/2010 18:14 EST (Skin Abnormality) Not Done: Not Appropriate at this Time T2: 3/5/2010 18:14 EST (Sensory Perception) Not Done: Not Appropriate at this Time T3: 3/5/201 0 1 8:14 EST (Activity) Not Done: Not Appropriate at this Time T4: 3/5/2010 18:14 EST (Nutrition) Not Done: Not Appropriate at this Time T5: 3/5/2010 18:14 EST (.Moisture) Not Done: Not Appropriate at this Time T6: 3/5/2010 18:14 EST (Mobility) Not Done: Not Appropriate at this Time T7: 3/5/2010 18:14 EST (Friction and Shear) Not Done: Not Appropriate at this Time Order Comments 01: Ped Skin Assessment on Arrival Ped Skin Assessment on Arrival 02: Adult Skin Assessment on Arrival Adult Skin Assessment on Arrival ~~ ~ , ~ , ~~ ,, cap ~ ~~e ~ < i , Date/1-imp Printc~e#: x/19/?.0,^ r.~;.~;~~. ~.~~- ' . ,. . . Printed By: Shiner, crystal L PENN~TATE HERSHEY ~ Miiton S. H~r~~~~ Patient Name: GARLAND, TIARRA J N9RN 7506936 Lines & Procedures Documentation .. Recorded Cate. _. 3/612010 - 3/82Q10 < Recorded Time 12:20 EST OQ:01 EST Recorded By Smith, Barbara A Yufias, Erika Prooe~l~re' Units Penpheral IV Actwity ~ Discontinue Assessment IV Sde Condition ~ No complications ,. , , . ~ No complications IrifiMralion Score . . ., 0 ... ........ . .....: _,..:.p - :Phlebitis Score 0 0 >IV Flow/Patency No complications - ;IV Dressin /Activit ~ ...................9............ Y...... ~ Barid-A"id ................................_:................................... .............................: ................'................. f i ~ t ~ C ~ ~ l Printed By: ~~~hi~~er, Crystal L PENN~TATE HERSHEY ~1 Milton S. Hershey M~dic~l enter Patient Name: GARLAND, TIARRA J IVF=tiV i50G03u w .......................................~...,......,..._..... ,.....................,....,,.,.,..,...............,....,...,......~.M,.,....~.~..~......... _.....~. Respiratory Therapy Documentation ~.~.~...a ......................~._..~..,........_....} Recorded C3a#s 3/6/2(?'10 316~~:Q:: 3f6/2010 Recorded Time 13:45 EST a 0. 1=ST; .:: 04:Oi EST '. Recorded By Smith, Barbara A <. Yutas, Enka Yuhas; Erika Pic~edc~r~ Units .: >.. ;: _ -..-..5 ____ .._.. . . . ; __. _ - . _ ... _, _; None . .. ........._....._. ......... ..- _ ... Barriers to Leaming .. ........................ . ~ ...._...........-. -- -...... None evident : -~ - - ..............o . :None evident ' .. ....................:: ~ - Respiratory Within Defined Limits - WDLs .Recorded Date 8/5/2070 3f51'it~<;: ; Recorded Time 22:00 EST 21.3~.E~i''.?:::< ... _ .. Recorded By Yuhas, Erika , Yuhas; ~rrka ;; P~df~t~ :. Units ~ ~ .. _; 'Barriers to Leaming ~ ~ ~ ~ ~ ~~ ~ ~.~ None evidentO2 ~ Noneevident°~. Order Comments 01: IER Pediatrics Form IER Pediatrics Form 02: IER Pediatrics Form IER Pediatrics Form 03: Ped Admi12 Assessment Ped Admit2 Assessment ` ~~ << Date/Time Printe;:i: 5/~'~/~(2y^ n?.~^ '°^~' Printed fay: Shiner, Crystal !_ PENN~TATE HERSHEY ~1 Milton S. Hershey Me~ic~~ ~~~~~° Patient Name: GARLAND, TIARRA J MRN 7506936 .w..M.~w ..............~..__.._._._......~~._.._.__._...~......_....._...................................~.~,.....~...~,.~.,..~..~..,..~.._......_..~........v...~.......~...w.v...._............_.....................; Respiratory Therapy Time & Equipment Documentation `: Recorded Cate 3/5/2010 Recorded Time 16:46 EST Recorded By Thomas, Kris D Prflcedufe>:: Units ;:Patient Procedure ~ ~~ ~ Trauma RTtreatmentduration :minute 10 ;~ r rr ~~ ` ~ , ` e ., ftt~ Ir,~'"r~ ia~~7~t~ r.~~~ , F~ ~'rinted ray: shiner, Crystal L PENN~TATE HEE~SHEY Nli~.ton S. ~ersh~~,~ Patient Name: GARLAND, TIARRA J MRN 750693~i ,_..._...w....~....~.._~. V.,. .......................~~.....v....._~....y........................................_.... ~....~..,.. Intake & Output Clinical Range To_ tal from 3/5/2010 to 3/7/2010 ;Total Intake-~~~~~~~~~-~---- ~-~-----~ ~ ~ ;Total Output fluid Balance 1060 ............................ . ..................501.....................................................559....-...............................................> DatelTime Prir"`~'i: ~liQl?'??n ~~:~'!• ~n~' Printed ~y: Shiner, Crystal L ,,. • ~ e~ n,, ,.,, (+7 .-r PENNSTATE HERSHEY ~1 Miiton S. Hershey Patient Name: GARLAND, TIARRA J tvIRN 7506936 ......._~.........a...._....v.., .....................................V.,........_.~.........~..._..............._........_V..~.........._.w....................................... Allergy History __ __ Substance t51tCA R~ardeclI]~#a~tme recorded By ` .. . _ ._. 3/5/2010 22:13 EST Becker, Sarah Reaction Status Active; Estimated Onset ; ABergy Type Allergy; ::Reviewed By Levan, Jody ;Reviewed Date/Time 3/1 1/2010 1 1:24 :EST; Recorded On Behalf Of Becker, Sarah r rr~ ~~` r Datel~I_ime Printed: 5/19/2010 07:2^ r'~~;_ Printed By: Shiner, Crystal L ~'~NN~TAT~ ~F.I~~~~ll Milton S. Hershel Patient Name: GARLAND, TIARRA J MRN 7506936 ..~..v ..................~.......__..._v........`..._..._._~...a....~....._..................._...............a..V.,..._..,.,..y..._.....,.~..,......w........,..~.~_._V.,..~....~_...................~.v.., Orders .............................................................................................,,.........,................................................................,........,..............................,...........,...i Order Date~#"nne : 3!`t10 1-9;09 EST :Order. MRSA Surveillance (NP), Followup (g7day) tOrder Status: Canceled :Catalog Type: Laboratory Ordering:Physician:~~SYSTEM, SYSTEM :::.............................................................:....:.:...::....::................... ...._ ........_...................: . :Entered By: SYSTEM, SYSTEM on 3!6/2010 18:00 EST :Order Details: STAT, Source:. Nasal Swab, Clinician to Collect, collected at 03/1 211 0 1 9:09:23, g7days, 182 day, stopping at 09/03/1020:00:00 :Order Comment: MRSA Surveillance (NP), Followup (g7day) ................................................................................................................................................................................................................................. .; Order Dafeffilii~:;~6}~t1't~ t~+~v4 EST ; ___ __ ... :Order. Discontinue Diet Patient Discharged :Order Status: Discontinued Catalog Type: Dietary ::. ,.:. ;.Ordering Physician: SYSTEM, SYSTEM Entered By: SYSTEM, SYSTEM on 3!6!201018:00 EST Order Details: 03!06/10 i 4:54:08 ................................................................................................................................................................................................................................ Order Comment: discharge order Qrder 4ati3~"it.::~~ 11;57 EST. . Order. Discontinue IV Order Status: Completed :Catalog Type: Patient Care ......................................................................................................................................................... Ordering Physician:~Gyorfi, Justin:.R~ ::.:....................................................................................................................................................... Entered By: Smith, Barbara A on 3!6/2010 12:25 EST Order Details: 03/06/1011:57:00, ONCE, Stopping On 03/06/1011:57:00 Order Comment: Order Date~t~e; 3/St~t1~~ 11':57 EST; Order: Discharge. Order Status: Discontinued :Catalog Type: Patient Care Ordering ~Physician:~ Gyorfi, Justin:R .:............................................................:...................................................... .............................................................................................................................................................................................................. Entered By: SYSTEM, SYSTEM on 3/6/201 0 1 8:00 EST Order Details: Stable for Discharge, Attending: Engbrecht, Brett W, Requested Discharge Dt: 03/06/10 11:57:00 Order Comment: Ordef.Dat61TFFrie:::316121}!fl 11:56 EST , Order. Discharge Follow Up Appointment (Follow Up Appointment) (~atft/Ttt??F? lit ti1?a!'~: 1. !Z n-p.~~.. _rt , ~ nn ... v. ; ,~. Printed 4~y: ,:sf~irc4r, Cr~sf~l L PENIV~TATE HERSHEY 1 Milton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J .~.~...._~.~._.._.__..~_....___w...~__..~_~.....~w....~...._._.., ..........................Ord ers Order Dat~~tt~:; 3l6/~tl~~ 10:36 EST :Order. Communication to Nursing Order Status: Discontinued :Catalog Type: Patient Care ........................................................................................... Ordering:.l'hysician: Gyorfl, Justin:R::....__ ............................._ ........................._........................... Entered By: SYSTEM, SYSTEM on 3/6/201 0 1 8:00 EST Order Details: 03/06/1010:36:00, C-spine cleared. Thanks Order Comment: Order>Date~me:~lbl2~t'i~ :09:00 EST< Order. cephalexin (Keflex) .................... - ...._..................._... ..........................................................9...yP..._..............._Y.. . Order Status: Discontinued ;Catalo T e: Pharmac ::..... Ordering Physician: Gyorfi, Justin R Entered By: SYSTEM, SYSTEM on 3/6/201 0 1 8:00 EST Order Details: 300 mg, oral susp, PO, q6h, Routine, 03/06/10 9:00:00, 03/13/1010:03:00 ................................................................................................................. Order Comment: .................................................. F'rin•i~tt f_iy: ~hin~^r, C~,,rst-'I !. MRN 7506930 PEN~I~TATE HEEiSHEY M~1 Milton S. Hershey ~F~w~.ie~~ ~'e~~~,r Patient Name: GAFILAND, TIARRA J MRN 750693G ...~,...~__~...__._._~__....~,.~.._...~.....~~......~....__a..V ..................~_....~.Orders ~.._..~.~..~.._.~....~..w.. ..._..._.~..w__.~....._......~_..,.~...._....._...._ Order Datecie:3f1~~ 21;57 E$T .Order: Advance Diet as Tolerated Instructions :Order Status: Discontinued Catalog Type: Dietary Ordering Physician: Gyorfi, Justin R Entered By: SYSTEM, SYSTEM on 3/6/201 0 1 8:00 EST Order Details: 03/05/10 21:57:00, Starting Diet Plan: Clear Liquid Diet, Goal Diet Plan: Regular Diet, Nursing Instructions: Place separate diet order., Pediatric patient Order Comment: C7~rer D~'t~t~'':tt'~3f3~~# 2Q~3g Eft Order: MRSA Surveillance {NP), on Admission :Order Status: Completed :Catalog Type: Laboratory :Ordering Physician:~Engbrecht, Brett:W :.:::................................................................................................................................................. :Entered By: SYSTEM, SYSTEM on 3/6!201012:43 EST .... ..............................................................................................................................................................................................................................: Order Details: STAT, Source: Nasal Swab, Clinician to Collect, collected at 03/05/10 20:39:30, ONCE, stopping at :03/05/10 20:39:30, Collected, 3 day Order Comment: MRSA Surveillance (NP), on Admission Order Datef~me .~fb~2tklfl 2Q;~0 EST Order. bacitracin topical (bacitracin topical 500 units/g ointment) ,_.. ........ .... .......... . _.. . girder Status: Discontinued Catalog Type: Pharmacy iOrdering~Physician:~Setaliutr, Dhave :::::............................._................................................................::::.:(.:::,. ........_`_.,.`y ................ ;Entered By: SYSTEM, SYSTEM on 316/201 0 1 8:00 EST ~ ; Order Details: 1 app!, ointment, topical, bid, Routine, 03/05/10 20:30:00, 30 day, 04/04/1018:00:00 :Order Comment: ` DatelTirrie Printed: 5/19/2010 07:24 EDT '-' -~ "^~' ~ ' ~'.""' Printed By: Shiner, Crystal L PENN~TATE HERSHEY N~ilton S. Hershey N~e~ical Center Patient Name: GARLAND, TIARRA J MRN 7506936 Orders ___ _.... _ _. :Order patef~%ne.:.~f19:0 211:05 EST _,... Order. Physician Consult Request (Consult, Physician) :Order Status: Completed ;Catalog Type: Consults Ordering Physician: Gyorfi, Justin R Entered By: Martinez, Madeline on 3/5/2010 20:25 EST ................................................................................................................................................................................................. Order Details: STAT, Requested Dt: 03/05/10 20:05:00, Service: Ophthalmology, Reason: 4 y/o s/p MVC wth L forehead lac due to broken glass. R/0 glass in eye, I have or will contact the physiaan directly, ped surg 1141 .............................................................................................................................................................................................................................. Order Comment: _ __.. . _. Order DatefTin~e:3fb1~Oi019~5 EST .. Order. Dextrose 5% with 0.9% NaCI 500 mL + potassium chloride 5 mEq ............................................................................................................................................................... Order Status: Discontinued :Catalog Type: Pharmacy Ordering Physician: Gyorfi, Justin R Date/l'irn-~ Pry .. /':`~` , ., . ~..:~:~~. Printed 13y: Shiner, Crystal L P~~l(~~TAT~ H~~iSHEY Milton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J MRN 50693E ....,.~.....r.....~..~,..._...~..~......._..~...~.....~,.....~...~.._..~.~. .............Orders .....~.~....._....~.~..~,..........................__......~........_......................... Qrder Daf~a~rne3/512#!~d 19Q4 EST. ,... . Order Vital Signs :Order Status: Discontinued <Catalog Type: Patient Care Ordering Physician: GyoM~ .Justin:R ..::.:......................................_._ ...............---- --..._.._..._.._.. Entered By: SYSTEM, SYSTEM on 3/6/201 D 18:00 EST Order Details: 03/0511 0 1 9:04:00, q4h - Order Comment: C<rdee Date!'~ime~.15~2t1~~1 19:E13 EST Order: Neuro Check ;Order Status: Discontinued Catalog Type: Patient Care Ordering Physician: Gyorfi, Justin R :Entered By: SYSTEM, SYSTEM on 3/6/201018:00 EST :Order Details: 03/05!1019:03:00, q4h :Order Comment: .. ...... Order Da1el:`~-~~1~4~t119A2 EST; :Order: Ped Admit2 Assessment :Order Status: Completed :Catalog Type: Patient Care .................................................................................... :Ordering Physician:-SYSTEM,~SYSTEM~ ::::.................................................................................... En#ered By: Yuhas, Erika on 3/5/2010 23:24 EST ,Order Details: 03/05/1019:02:48 :Order Comment: Ped Admit2 Assessment Qrder't~ate~me ~/5)2Q#119:02 EST ;;:.: ..........:..: Order Level of Care: Floor Order Status: Discontinued ;Catalog Type: Patient Care Orcierng:.f'hysiciari: SYSTEM, SYST`EM :::::................................................................................... Entered By: SYSTEM, SYSTEM on 3/6/201018:00 EST Order Details: Request Dt: 03/05/10 19:02:48 Order Comment: Level of Care: Floor Ordef D~tetrie:3t5t2d1fl 1942'EST .,.,, Order: morphine ate/Tin~o rintecJ: .9/.-. I°'rinteci Lay: Shiner, f crystal L. ~ENN~TATE NERSHEY /~1 N~ilfion S. Hershel Patient Name: GARLAND, TIARRA J MRN 7506936 •...~_.~ .....................~~.....~..~........V...........,~.._.........._.............._...................._..... ....._...V....w......_...._.........._........,........~......~....,......._..~.a ....................... Orders .Order Dat~~me.3/5/2tlA '19cQ2 EST _. .. Order Med Dosing Weight (Dosing Weight) Order Status: Completed ........................ Ordering~~Physician:~Gyorfi, Justin:R::: ..:....................... Entered By: Gyorfi, Justin R on 315/201 0 1 9:02 EST Order Details: 03/05h 019:02:00 Order Comment: ;Catalog Type: Patient Care OrderDatefTfFne:3f5/2~1~ta 19:01 ,EST Order Shoulder XR (OXSHOULDER) :Order Status: Completed Ordering Physician: DeFlitch, Christopher J Entered By: , on 3/51201019:04 EST Order Details: STAT, Requested Dt: 03/05/1019:01:48, Views: `Standard Views Order Comment: Omer R~f"rrtre•.3f5-~o 19:~ EST' .... >Order. Clavicle~XR~(OXCLAVICLE) Order Status: Completed Oatalog,Type:_Radiology Ordering Physician: DeFlitch, Christopher J Entered By: , on 3/5/2.010 19:04 EST ............ ........ ....... ..... .......................................................................................................... Order Details:~STAT, Requested Dt: 03/05/1019:01:48, Views:'Standard Views Order Comment: _. . :,: r er ate; . ~rr1~: ..::., `~t1 79:01 EST .. Order: Social Service Consul/ Order Status: Discontinued ;Catalog Type Consults .................................................................................... Ordering~Physician:~Gyorfi, Justin:R:.~ ::.................................................................................... ........................................................................................................................................................... Entered By: SYSTEM, SYSTEM on 3/6/201018:00 EST Order Details: Priority, Requested Dt: 03/05/1019:01:00, Trauma Assessment Order Comment: n~.tE~/Tir*a .~.a.... ~: ;I"^l.'~`~t~? n7 ^~~~ Fr`_ ~~ ;,, jn.+ Printed By: Shiner, Crystal L PENN~TA~~ ~~,~~I~t 1 Milton ~. Hershey Medical Cen~~~- Patient Name: GARLAND, TIARRA J MRN 7506936 Orders rder Daf,~~r~te 3/5i2Q~Q 19D0 EST ': :Order: Peripheral IV Routine Care r er Status: Discontinued :Catalog Type: Patient Care ........................................................................................... ~Ordering:.Physician:~Gjrorfi, ,Justin..R..:... :......................................................................................... Entered By: SYSTEM, SYSTEM on 3%6%201 0 1 8:00 EST Order Details: 03/05/1019:00:00 Order Comment: der Datetne 3tb~~ 19OQ EST . ... .:. ;: .......... . . _ .::.,. Order. Intake~and Output (I&O) r er Status: Discontinued Catalog Type Patient Care Ordering Physician: Gyorfi, Justin R :Entered By: SYSTEM, SYSTEM on 3/61201018:00 EST _. :Order .Details: 0305/1019:00:00, gShift ............................................... :Order Comment: Order Date~:Ctri~;~-~fl 19'oQ SST ~::: . _. Order: Communication to Nursing ;Order Status: Discontinued ... _. Calalo9_TYPe:..Patierii Care Ordering Physician: Gyorfi, Justin R ...... ...................... ........................... Entered B SYSTEM, SYSTEM on 3/61201 0 1 8:00 EST ..................y'..................................................................................................... rder Details: 03/05/1019:00:00, Tand Lspine cleared, head of bed > 30 degrees. ....................................................................................... Order Comment: r er Da~E~/rrX[e;3/5f211#~ 19c00 EST >: .Order: Communication to Nursing ....... _ Order Status: Discontinued Catalog .Type: Patient Care Ordering Physician: Gyorfi, Justin R ................................................................................................................................................................... Entered By: Gyorfi, Justin R on 3/6/2010 10:36 EST Order Details: 03/05/1019:00:00, C-spine not cleared, patient to remain in c-spine collar. Order Comment: llate/Time F'rinfi:^~: !"i~~'~^^y^ r~-r.R., --°._. Printed By: S{~siner, Cr jfsfal L PENN~TATE HERSHEY Milton S. Hershey Mecii~~1 ~~nt~r Patient Name: GARLAND, TIARRA J iJfRN 7508936 ...__~_____.~___~_..__~__...._~___..~...~..~___..~.._.......~..~ ...........................Orders __.._~.._~._~....~,..._w_.~..._.w_._.__...~.w.__~--_.___......__~.~....~.._.__..___.... Order Dafe~me_ 315i'2~?'i!#t 18;59 EST Order Vital Signs , .................................................................................................................................................................. Order Status: Discontinued .Catalog Type: Patient Cara Orclertng:.Ph}isician:~Gyorfi, Justin:.R :.::.:........................................................................................... Entered By: Gyorfi, Justin R on 3/5/201 0 1 9:04 EST Order Details: 03/05!1018:59:00 Order Comment: Order'Dateiris: 3t$E;~11it118;59 ES7 Order: Up Ad Lib Order Status: Discontinued :Catalog Type: Patient Care ,... .. Ordering Physician: Gyorfi, Justin R ~ ~ --~ ~ ~ ~ ~ ~ -~~ ~ ~ ~~~ ~~~ ~ ~ ~~ Entered By: SYSTEM, SYSTEM on 3/6/201018:00 EST Order Details: 03/05/1018:59:00 Order Comment: Order DatefTEirte>~Ib~11018fi9 EST ..................................................................... Order: Admitting Diagnosis i]at~~!°i'i~:t^ Printed: 5/1^/^€` i~3 07:^~~ ~ D f .;~ y :. ,, Printed By: Shiner, Crystal i_ FENN~TATE HERSHEY 1 Mi~.ton S..Hershey Medical ~e~~r ar~nt f'~• ~f ~~~:3: C~/',I ~t_~ '...~, ::; ,~ ~ ~e :., (vil~6d /50U9;3G Orders :Order Da~Ee/Tirtte ~/a1~ .18;58 EST :Order: Admit. .............................................................. r er Status: Completed :Catalog Type: Patient Care ........................................:.......................................................................................................... 'Ordering:Physician: ~Gyofi, Justin:R::::.._ ......................._...................._.._..................................................................................._... '.Entered By: Forshey, Mary K on 3/5/2010 19:09 EST Order Details: Routine, Requested Admit Dt: 03/05/10 18:58:00, Admit, Floor, 7th floor, Peds Surgery, Engbrecht, Brett W, Trauma admit, LOS: 2 days Order Comment: :- r~-er Date~rri~: ~t51~~~t 1:55 EST ',Order. Ped Skin Assessment on Arrival ......................................... . r er Status: Com leted :Catalog Type: Patient Care :::.:;::.::~>::.;.::~ .:::::::.::p.>.::>::.... Ordering Physician: SYSTEM, SYSTEM Entered By: Yuhas, Erika on 3/5/2010 23:22 EST Order Details: 03/05/1 Q 18:55:00 Order Comment: Ped Skiri Assessment on Arrival .. . Order Da.:.::.. arrt~: 315f~t1~~ 18:3 SST Order: T-Spine CT (OCTSP) Order Status: Canceled ~atalo T e: Radiolo 9... yp . ...............9Y Ordering Physician: Scholfield, Kimberly R Entered By: , on 3/5/2010 19:18 EST Order Details: STAT, Requested ~l]t: 03/05/10 18:53:05 Order Comment: ... r er Da~a~rrie 5>2~'~t# '8:50 EST' ,: :: ,_ ,. ;Order: Pelvis CT {Iliac Crest to Symphysis Pubis). {OCPELVIS) Order Status: Canceled ;Catalog Type: Radiology Ordering Physician: Scholfield, Kimberly R Entered By: , on 9%5%2010 19:18 EST Order Details: STAT Requested Dt: 03/05/1018:53:05 Order Comment: DatelTime Printed: 5I19/'?~'~'~ n~.~^ t'~~- Printed By: Shiner, Crystal l_ PENIV~TATE HERSHEY Patient Name: GARLAND, TIARRA J MRN 7506936 .~ .................~...~..........,.......,............a,.~........................ ............. . Orders Order Dat~Time;: 3/5f~#l:~~i'18.53 EST,. .Order: Facial Bones CT (OCFB) ...................................................................................................................9 .. Yp...................9y Order Status: Completed Catalo T e: Radiolo Ordering~Physician:~Scholfield, Kimberly~R~~~ ~ ~ ~ ~~~~~~~~~~~~ ~ ~~~~ ~~~ ~ ~~ ~~~~~~~ ~~~ ~~~~ Entered By: , on 3%5%2~10~19:55 EST.......... Order Details: STAT, Requested Dt: 03/05/10 18:53:05 Order Cammerit: Order DatelTEne:3151~~018:53 EST Order: C-Spine CT (OCCSP) r er tatus: Canceled ._:. Catalog Type: Radiol :Ordering Physician: Scholfield, Kimberly R :Entered By:., on 3/5/201019:18 EST Order Details: STAT, Requested Dt: 03105/1 0 1 8:53:05 :Order Comment: Order Dafe~#ir~ti~;.313!:~~ 1~'~3 EST> :Order. Chest CT (Apex to Adrerials). (OCCHEST) ......: ;Order Status: Canceled ~~ ~ ~ ~~ :Catalog Type: Radiology :Ordering Physician: Scholfield, Kimberly R Entered By: , on 3/5/201019:18 EST :Order Details: STAT, Requested Dt: 03/05/10 18:53:05 Order Comment: Order Date~me ~~51~f)~~11g 53 SST :Order Abdomen CT (Diaphragm to Iliac Crest). (OCABDOMEN) .. ~ Order Status: Canceled __ Catalog .Type: Radiology Ordering Physician: Scholfield, Kimberly R Entered By: , on 3/5/2010 19:18 EST Order Details: STAT, Requested Dt: 03/05/1018:53:05 Order Comment: Order Date/Tfn~ia.~fb1~1~1! 18:40 EST ;.. Order Green on Hold in Laboratory (EXTRA GREEN (LIHEP)) rder Status: Completed ;Catalog Type: Laboratory~~~ ~~~~~~~~ - Ordering Physician: ~Scholiield~:.Kimberly:R :.:::............................................................................................................... ..:.. : Entered By: SYSTEM, SYSTEM on 3/7/2010 01:32 EST Order Details: Routine, Collected at 03/05/101840:00, Ordered by the lab, 3 day ~ ~ , Order Comment: , , , ~~-::~_°/Ti~r~e Printed: 5/19/20?!~ ~7:2~• EC~T F~a~.-_ -~~~..- Printed By: Shiner, Crystal L ~~ ~ENIV~TATE HERSHEY Mi~.ton S: Hershey Medical Center Patient Name: GARLAND, TIARRA J .............~.w..~........_.......~..........._...~_.~.._...,..__.........._........._..............~v..w Orders Date;/Time Print;~~: ''/'~/,^~~,, n~;^,~. '''~-~ Printod By: Shiner, Crystal L MRN 7506936 ~r~ ~, `E~.. PENf~~TATE HERSHEY ~1 Milton S. Hershey Patient Name: GARLAND, TIARRA J MRN 7506936 ._.,._..___~______~_~ ..............~....__.~_____.__..........,~_.._....._._....___........__..Orders ___~.~_..~~._.~.....~....,._.._w..~.~....._..__._~__.___.._...._~-_~--___._..._.._.._._.. DatelTime Printed: 5/19/2010 07:?_~d C:L~T Printed By: Shiner, Crystal L ~.~, PENN~TATE HERSHEY Nrilton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J MRN 706936 ..v.....,......v....~_...w .............._.~.........~..k.`...V.....w_..~...................._...................._~..~.........,._......_~............_.~.~.~....~..................v........~..............., Orders _. (order Dafia~me .3~8f~Q#018::33 EST; .. Order. Complete Blood Count w Differential (CBC w Platelets and Diff) Order Status: Completed Catalog Type: Laboratory .. ... -:::::.olfield:.Kimberl.::R .::::...............................:.................................................................................................. :Ordering Physician: Sch y :Entered By: SYSTEM, SYSTEM on 3/5/201019:38 EST :Order Details: Stat, Blood, Clinician to Collect, starting at 03/05/1018:33:00, ONCE, 3 day, stopping at 03/05/10 :18:33:00, Collected :Order Comment: [[Lavender tube; Panel indudes WBC count, RBC count, Hgb, Hct, Platelet count and Differential]] ,Order C7at~fi~tlle:.3t! 18:33 EST :Order. Blood Type/Antibody Screen (Type and Screen (for possible tx)) ..........................................................................................:.......................................................................................................................................: :Order Status: Completed Catalog Type: Laboratory Ordering Physician: Scholfield, Kimberly R :Entered By: SYSTEM, SYSTEM on 3/5/201 0 1 9:36 EST :Order Details: Stat, Blood, Clinician to Collect, starting at 03105/1 0 1 8:33:00, ONCE, stopping a103/05/1018:33:00, Col- lected, 3 day :Order Comment: [[Pink tube; Deliver to Blood Bank. Additional Blood Bank arrn band and requisition are required (R num- ber identification).]] Order I]at~f~`rt~te:>3J~#1:~~.1833 ES'~ ...... ....................................................... Order: Amylase Level (Order Da~/Ttrne~3~612t1~i1<1833>EST Order: ALT Level Date/?'ime Pri:ited: 6/14/2~'1(?7:^^.• r-;n~- Printed By: Shiner, Crystal L ~~' <<. >~~~,~~~~~uT~ ~E~.~~-IE~ Nli~ton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J MRN 75U69:fi ._~__.~_____________~..._.____v....~~_~...~_......._.._._.~.~..._._......_..~..___._____._._Orders IJrder Da~~lTirie::3~~~.hZQ'~fi 1831:EST ,...: _ _ :Order C•Spine XR {OXCSP) ;Order Status: Completed Catalog Type: Radiology :Ordering Physician: DeFlitch, Christopher J Entered By: , on 3/5/2010 19:04 EST :Order Details: STAT, Requested Di: 03/05/1018:31:37, Views: "Standard Views !Order Comment: Order Date~trie:::3fb/2#1:#Q 1&31 EST Order. Pelvis XR (OXPELVIS} girder Status: Canceled Catalog Type: Radiology Ordering Physician: DeFlitch, Christopher J Entered By: , on 3/512010.18:43 EST Order Details: Routine, Requested Dt: 03/05/10 18:31:15, Views: "Standard Views Order Comment: Order Dat~f~`kt`#t8:3f.~f.~p 18:30 EST - ; ` :' _. _, . Order. Cheri XR (OXCHEST) Order Status: Completed Catalog Type: Radiology ......................................................................... Ordering Physician:~DeFlitch, Christopher J:.::: ..................................................................... Entered By: , on 3/5!201018:42 EST Order Details: Routine, Requested Dt: 03/05/10 18:30;48, Views: "Standard Views Order Comment: Order Date~tne :~1.~1~Q:'~t118•'14 ES7 _ .....:: Order Safety Wristband Verification Order Status: Discontinued :Catalog Type: Patient Care ................................................................................... Order'ing:.l'hysician:~ 8YSTEM, SYSTEM :::::................................................................................ Entered By: SYSTEM, SYSTEM on 3/6/201 0 1 8:00 EST Order Details: 03105/1 0 1 8:14:59, Midnight Order Comment: Safety Wristband Verification Entered By: SYSTEM, SYSTEM on 3/5/201018:14 EST :Order Details: Request Dt: 03/05/10 16:14:58 :Order Comment: ED Visit r')2~t.~/: s.'. ~:; Printed: 5/19/010 07:;-: ' ' -: . I,rinted By: ~ Shit~or, Crystal I__ PENI~~TATE HERSHEY /~1 Nri~ton S. Hershey Nledica~ Center Patient Name: GARLAND, TIARRA J Date/Time Prin±,^~: '°/t^•/.^n,yn~ r~7:''.n. rnT Printed By: Shiner, Crystal L MRN 7506935 <<„ o, ~. ~ -~ P£N(~~TAT£ H£RSH£Y Milton 5. Hershey N~e~dical Center Patient Name: GARLAND, TIARRA J MRN 7506936 Medication Orders .:.. .. _ .. ....... .............. ~Jrder Da~Eta~me 3~6/2~k1fl 13 t!3 EST __ . ._ .Order acetaminophen-codeine (Tylenol with Codeine oral liquid) Order Status: Ordered Ordering.:Physician:~ Nlclni}rre,James S ....... ...... .............. . Entered By: McIntyre, James S on 3/6/201 0 1 9:03 EST Order Details: 5 mL, PO, q6h, Disp: 140, Refills: O, Start: 03%06%10 13:03:33 Order Comment: rder Datef#"Fme:: aft'. rr~tl3~i 11:b3 EST Order: cephalexin (Keflex) __. ....:.:. ......; :. :;Order Status: Ordered - -- ~rdering Physician: Gyorfi_, Justin R ~~ ~~ ~ ° `''' ~ `' .. ;:Entered By:~Gyorfi,~Justiri R on 3%6%201011:54 EST :Order Details: 250 mg, PO, q6h, Disp: 0, Start: 03/06/10 11:53:41 :Order Comment: ........................._.............. ... Order Dat81Ttttte..3~61~4~009A0 EST . , ..., ,. __ _......_...... Order cephalexin (I<eflex) _ _ ; ` ..:............ .::: _ _ .. .Order Status: Discontinued - ............ ......... ...... ...................... U dering Physician: Gyorfi, Justin R ::Entered B SYSTEM, SYSTEM on 3/6/201018:00 EST :..................Y:.......................................................... ........................................................................................................ :Order Details: 300 mg, oral susp, PO, q6h, Routine, 03/06/10 9:00:00, 03/13/10 10:03:00 ::............................................................................................. ;Order Comment: ......._ ...... ................ ..._._...............--..............__ ._. __ _._ ........................... er Date~rri~;:3~32~'30 07:25 EST, ..,. -, ;... :: :Order: ondansetron (Zofran) . ,.. _.. ................................................................................................... ......................................................................................... . r er Status: Discontinued ;Ordering Physician: ~Gyorfi, Justin:R :::.:............................................................................................................ .............. ;Entered By: SYSTEM, SYS'fENl~ori~3~Ei/201018:00 EST Order Details: 1.5 mg,, irijectron, IV, q6h,. PRN, Nausea, Routrne, 03/06/10 7 25:00, 30 day, 04/05/10 7:24:00 Order Comment: -~ - ~~ ~~ ~~ ~ ~~ r, ave Entered ~By: S.YSTEM, ~ SYSTEM on 3%6/201018:00 EST Order Details 1 appl, ointment, topical, bid, Routine, 03/05/1 0 20 30:00, 30 day, 04/04/10 18:OI7:Q6 Order Comment: ....................................................... Date' n... .,..~, .7., ~ r.... L ~fa'~ .... ... ., .. - nrinted Lay: Shiner, Crystal L PENN~~ATE NERS~E~~ Milton S, Hershey Mescal Cent:~x Patient Name: GARLAND, TIARRA J MRN 750693G ..~.._...~.~~._.___.~___._.w._.__.~........~_..~.~..~.._._.M_.~.......----Medication Orders .v...~_._~._.w_.._w..~._..w.....~_..~......~~._....~..~ .............. Drder Date~'rme :3~~s12E1~019Q6 EST :Order: acetaminophen (TYlenol) Order Status: Discontinued ;Ordering:.Physician: Gyorfi, Justin:R::::.... _ ......................................................_........................................._......................_.. :Entered By: SYSTEM, SYSTEM on 3/6/201018:00 EST :Order Details: 200 ~mg, drops,. PO, q4h,. PRN, Fever/Pain, Routine, 03/05/10 19:06:00, 30 day, 04/04/1019:05:00 :Order Comment: dose modified per pediatric standard dosing Order ,,;:..:F~:~?:.::.:...:. _. L~rcler: Dextrose 5% with 0.9% NaCI 500 mL + potassium chloride 5 mEq Drder Status: Discontinued Ordering Physician: Gyorfi, Justin R :Entered By: SYSTEM, SYSTEM on 3/6/201018:00 EST Order Details: 500 mL, IV, Routine, 03/05/1019:05:00, 30 day, Hard Stop, 04/04/10 19:04:00, 50 mVHR, 10 HR, 500 Order Comment: vraenng rnysician: cayorn, Austin n :............................................................................................................................................................................................................................... :Entered By: SYSTEM, SYSTEM on 316/201018:00 EST .:............................................................................................................................................................................................................................... :Order Details: 0.75 mg, injection, IV, q2h, PRN, Pain, Routine, 03/05/10 19:02:00, 3 day, 03/08/10 19:01:00 Order Comment: l , V . ~ f L 1 l 1 t !l?~`~_~'i~`, R ~',-,~•~,-!: r.,/1A/n1,~n R'T,?n rF'?T r1~,~-.., .. , n~ Printed By: Shiner, Crystal L PENN~TATE HERS~E`~ Milton S. Hershey ~.~~°~!~~~.~ ~~nr Patient Name: GARLAND, TIARRA J ~~i'-~i~ ~Ia0G93~i .......w..v,,..~._..w._..._..~~.~........., V.......~......_~...,._....~. .....................................~..~.......... ..~,..,........~..,......~,~...,.~...............~......,~..,.~........................~ Medication Administration Record Medications ;; Admin Da#efi'ime 3/6/2ik10 1315 EST Charted Daie/Tlme.3t6/~41013 24 EST ~Medicalion Name: acetaminophen (Tylenol) ingredients: ACET100D 200 mg 2 mL Admin Details: (Auth) PO Action Details: Order: Gyorfi, Justin R 3/5/201019:08 EST; Perform: Smith, Barbara A 3/6/2010 13:24 EST; VERIFY: Smith, Barbara A 3/6/201013:24 EST Reason for Medication: Smith, Barbara A 3/6/201013:24 EST Fever/Pain _.. __. Adr~tn e1`t'tme; ~f.6121~10 1t):2o EST Charted b~ielTtttte:~6f~4~1~? ~Q'18 EST Medication Name: cephakxin (Keflex) Ingredients: KeNex 300 mg Admin Details: (Auth) PO Action Details: Order: Gyorfi, Justin R 3/612010 08:42 EST; Perform: Yuhas, Erika 3/6/201010:18 EST; VERIFY: Yuhas, Erika 3/6/2010 10:18 EST ~-d„mIn ~a#e/"Cl; 3/x/10 07:40 EST Charted Paie/Tirfli$;:;3l~f2~~~47"41 EST . ... :Medication Name: ondanseiron (Zofran} :Ingredients: ONDA2121.5 mg. 0.75 mL :Admin Details: (Auth) IV, .IV, Peripheral Action Details: Order: Gyorfi, Justin R 3/6/2010 07:25 EST; Perform: Yuhas, Erika 3/6/2010 07:41 EST; VERIFY: Yuhas, Erika 3/6/2010 07:41 EST 'Reason for Medication: Yuhas, Erika 3/6/2010 07:41 EST :Nausea Admin DafeF1€'1: ~/6I~~0 07;25 EST Charted OatelTlm~ez31~/~3'1fl:t}~37 EST Medication Name: bacitracin topical (baciiracin topical 500 units/g ointment} Ingredients: BACOTI5 1 app/ Admin Details: (Auth) topical, Wound Action Details: Order: Setabutr, Dhave 3/5/201022:16 EST; Perform: Yuhas, Erika 3/6/2010 07:37 EST; VERIFY: Yuhas, Erika 3/6/2010 07:37 EST :Medication Name: morphine :Admin Details: Final 'Pain Intensity Response: Patient sleeping Action Details: Order: Gyorfi, Justin R 3/5/201018:58 EST; Perform Erika 3/5/2010 23:05 EST ,,, Yuhas, Erika 3/5/2010 ~~:0.5 EST;;VERFY: Yuhas, `<t , Data/(i~,~::.::_.,_ . i ~,:,_... ~~...... ..,_ . Printed By: Shiner, Crystal L PENN~TATE HERS~-~EY Nrilton Ss ~Iershey Medical ~~n~r Patient Name: GARLAND, TIARRA J _.~.._V... .............................w.........,..._......,.......V..~,.._.............._..............................~....._...........~............ Medication Administration Record r ...................................................................................................................................................... Medications I'~IRN 750693E ., Admin L3ai~efFin}e "3I5/2~?10 22 35 E'S'T Glharted Da1elTir~e' .Medication Name: morphine Ingredients: MORP21TU8 0.75 mg 0.38 mL :Admin Details: (Auth) IV, .IV, Peripheral :Pain Intensity Response: 2; Pain Scale Primary: Wong Baker Pain Scale _....._ . :Action Details: Order: Gyorfi, Justin R 3/5/201018:58 EST; Perform: Yuhas, Erika 3/5/2010 23:05 EST; VERIFY: Yuhas, Erika 3/5/2010 23:05 EST :............................................................................................................................................................................................................................: Reason for Medication: Yuhas, Erika 3/5/2010 23:05 EST 'Pain :................................................................................................................................................................................................................................. .... ~dmirl Date1`#`i~11d: 1201p 2p30 I*ST Gha~tedC p~tell`ime3/~10:21;55 EST Medication Name: bacitracin topical (bacitracin topical 500 units/g ointment) :Admin Details: (Not Done) Not Appropriate at this Time :bacitracin topical _. . :Action Details: Perform: Yuhas, Erika 3/5%201020:30 EST Resuk Note: Yuhas; Erika 3/5/2010 21:55 EST :already done in ED when sutured ..,.......,.....,.~,~..,,.., .............................~....v.,..v..~.....~...........,.,.,....,....,.,,.,..V.,..,~.,,.~..,.,..,...~...,.,.,..~..~..,v...,..,.,.,.,..~........M.......,......,.................,,.,,.,..,,...~ Continuous Infusions ,~-dtt1i11 l~itet'1~.:3/612010 00`t 5 I*Sl` Charted >JatelTime:31#'.rf~T~ t3~J-19 EST ...... .. :Medication Name: Dextrose 5°~6 with 0.9°k NaC1500 mL + potassium chloride 5 mEq :Ingredients: KCL2110 5 mEq 2.5 mL; D5NS500 500 mL :Admin Details: (Begin Bag) (Auth) 500 mL, 50 mUHR, .IV, Peripheral :Action Details: Order: Gyorfi, Justin R 3/5/201019:05 EST; Perform: Yuhas, Erika 3/6/201000:19 EST; VERIFY: Yuhas, Erika 3/6/2010 00:19 EST ,` F r ` ~.' ,. ~,~ !?~t:;/Time Printed: 5/19/201E1 Q7:''^. !-nr Printed By: Shiner, Crystal L :, ~~,_~ PENNS~ATE HERSHEY Milton S. Hersey i ~~~+ ~ ~ x~~ ~° ~: _ _ Patient Name: GARLAND, TIARRA J MR~I 7506936 .,~.._._~.,._...~.,.~.,..._..a~ .......................Problems __~_~---__--__._._.~.__~~...__......~__.._..~....__.....~.~__~.~._.__~......_....___... ~~tc~/Tirn;- ;Tinted: 5/19/2019 07:^ ^.. ~.=,!~"r Printed t3y: Shiner, Crystal L ~~ ,. ~. PENN~TATE HERSHEY ~1 Mi~tan S. Hershey Medical Center Patient Name: GARLAND, TIARRA J ,F~i~;PJ 75OC;93v Height Nileight Measurements ...............................................................................................Weight........................................................,.............,............................,.. Recorded Date 3/x/201 a Fiedor~ed Time 21.:30 EST €3ecorded By Yuhas, Erika .. ~ f'rocedt#e :: Urt~is .. Patient Weighs ~cg 15.00001 ::..............................;............................................................ Order Comments 01: Ped Admit2 Assessment Ped Admit2 Assessment Date/Time Printed: 5/19/2010 07:?4 ~~T Printed By: Shiner, Crystal L <<< R S A F~ R a ,S n _. ,-_ 7 !~ Patient Name: GARLAND, ~fIAFiI~H J Date of Birth: 10!312005 PENNST~TE ~!E~SF~E~' ~, _ ,., , s - PENN STATE TRANSFUSKMI . ` _ `Alq~~ Q 77,r,~~~~~~I~~~YI~ -~ ~ ~ ~ R1 ~ 7653 LAY. 7SOOi9i ~ ~~3e NILIONS. HERSHEYMEDICALCENTEA LO: ~OEFtI7q( f7f 00~f: 1pbOBB9b _ BLOOD RANI( 008r Of 0111000 Ib70 L0/1; y12b ~ DIRECTOROFC~INICALLABORATORIES ^CRO$SNATCH (xul `^ r ~RPA f ~! ~~~~ 04/2!/2010 _ . Z. 4.8. BOFKilOVM1NL N.D. (AB01RH. ANTIBDDY SCREEN, UNrTSI -N~II[1~01~~ !d` 3%~~F PAY ~Q SPECIAL REQUESTS - CALL x'232 COMPONENT YUNRg 1Y / - - ~ - - - _ - - - PACKED CELLS gKiNATU ^Exrr•+ANr~IRANSFUSION GRANULOCYTES 01LfG1 ~ - TINE~~u Y ~J V~ RECIPIEN7SID ICATIONYEAIFED,~/ DAIS; ^311TiAU'IERINETRANSFUSION HPC•STEMICEL.LS P0~6iS1 I Q ~ SPECFNEN OOLIECTEDA/VD BLODD BAND APPLIED e ^FRESN (LESSTHAN 8 GAYS) TYPE AND SCREEN t'r$c1 MrFORfIAATiON REQUIRED 0 UNIT$ NBO/RH, ANTI$ODY SCREEN, 0 UNITS) ~f~y~~~ TAT . j,..OQ ~ ^IEBS THAN M HOURS ^ DB TYPE AND SCREEN (OBTSI DIAON031S -! • `+~L7tY\C~ ~~ ~ , s. tf1Q~p IPEDIAIRICFEVTfSURGERY) (ABOIWi.AfiTiBOOYSCREEN,DUNIT31 ORDERIN(aPHYSICI/W ^ROUTINE ¢. ^ NEONATAITRANSFU810N (NEO)Q FORSUROERY ~V E~~' (~ ^OTHER (ABOlRH. ANTIBODY SCREEN) ~ pA~ M FOR TRANSFUSION I• CUNICALPAIHOLOGI ~N ^ HOLD SPECIMEN IHDI.DI ~ REpU ~ (Np TE$TINp PENpING ORDERS) KEEP__ UNITS AHEADATALLTILfE9 .~ ^ ~ ~ 1 ADULT RED PER 4 UNR6 (NEW 6PECMA<AI REOUSfED EVERY 7Z HDURSI ~` ^f!~rAOUT>:D EACH 7u01: Lg18T NAVE RIf LAOEL PREVIOUS TRANSFUSIDN6 OVVISI{EO ^ YEB ^ NO DALE CHART COPY • f f ( ~ Y r ~ ` ~ f t ~ - ~ ~ t, 1 • 1 _ .. ~,nlxsr(RS:va~n C4INICAL LABORA'I°URY hv~~~~#~~" ~i-~~i=; 1' ------ -- - --- - - ; i Facility: HMC C'acre i 21 of 143 PENN~TATE HERSHEY Milton S. Hershey Medical Center Patient Name: GARLAND, TIARRA J MRN 7506936 ......... ................~................~~......~.;~.~.~.......~ .....Scanned Inpatient,Chart.......................................................................... ~ LL 4 l l (~ ( F- ~ n't~(T!r°t^ P"`~rx~r+; ~/?c~/?f?1!~ ~7~a~. r-n-~- i3~~ir~ced ~y: Shiner, Lrystal L f l ( ~ 1. n.. T.. ~~~ r,R '~~o F'atlent Name: CaAFiLHNU, ~ li~l il-{H J w....:: ; ..i ; _. - Date of Birth: 1 D/3/2005 F{N: 10506S:3S PENNSTATE HERSHEY ,- J- --- -- - - ~--- ~-- ~---- I~~II~~~IInNl~l~l~ rows: Truuua, rsoeeae wRr. rsoevaa Dose: rososeae wn: pEFL,ITCH pIFi3,°,TO t7A: 06325 UQa: e1 /t71 /5G+G0 ': t;3IT r.'.~'t": f. ;1:'t`=flti ._ a. _,........__, _~,.....:.- LAC: EVER .~zX: u TRAUMA HISTORY AND PHYSICAL EXAMINATION I ~ P ~ sE" `~'Y Ili 11~1~ .- - -- - - ------_- • • • Date: ~ G ~ !J (~ Time: ~ ~~ Type of Trauma Brief l~istoiy ~Niecban~nt`Cn~~-'j~ ", '` ~ _ :" ~ .~ r t~hllVC Betted? ~i~lfYes ^ No O Airbag ~ yja i' _ D Pedestrian ^ MCC C] Assault Urt~ ,p - ^ Fall ^ Bum ^ Electrical » ~I ~ ~ ~ .. ^ GSW ^_ Stab. ^ t~tler \ e'itf R~sittt~ . rY .h ,'M ~ ~ ., r Airway: ~r flPS: ~>r. R.D.S. ~, ,~ Field Vitals: P: BP: RR: Immobtlimtian: ~ Fluid: ~ r~ju Amnesia? ^ Yes ^ No Loss of Consciousness7~Yes ^ No Field Notes: ~, ~s Primary Survey : ~. r ~ ~. - : Tratwtta Hittorya ~ ., ~ . ~ - : y " Abway:'~(iPat6nt ^ Dbstructed Incubated: ^ OT ^ NT ^ Tracb Alkrpies: &eatbing: (n Bread Eaanda: ~t~,'t Nkds: Clttdulettan: P' 13P: RR: Sat: D6abitfly: Alen ocal ^ Painful ^ Unresponsive PMW: Etgpoaure: Pracedarss: ^ NG-Tube Urinary PSH: ^ A-lino: (s1: Chest tube ^ r Lail Weal: Z ^ D - Leal Tataara: Secondartt Surrey 2nd vitals: Temp. P: ~,.. BP: R: ~ 02 5at:~ VYi k ~ NEENT: Head: Eyes: ;1 s 3 - ~. a ~3 - ~ ~~ ' Ears: TM's: Bat11e's: Face: MaxiYa: Mandible: ~ ~_ - Nose: Dentitia: 1\ ~ , Mouth: Dentures: ~ \. r ' Neek: Tenderness: Crepftus: Trachea ML: ( ~ 1~° '• test Waal: Tenderness: -r Crepitus: ~ 1 111 ~ Lungs: y ~ ~ , Badt: Tenderness: Crepitus: I ` f `~ Head: hfllr+~Gv 5 AWomen: Distention: BS: Tenderness: -~ j ; ~ ; {~' ~~ < Rsetal: Tone e: Prosta e: ~ ,~~ Pelvis: Stable: Tenderness: ~ LEGEND: L -laceratirn Yascelar Exam: Rad ~Z, Femora{ k~ DP tZ RighULett BIt~C~ -- '----- PT ~ 1 J , ~ ~, =dam , ~ ~~, fracture ~.; -open < INsfdeat Sigeature ~;_. Title QC~ Date 3 /s"~o Time a.m. s ors ~ ~ fracture 'Ab, -abraefq*, , , c -camsix, ,` ts9e PBONS ~ ~ ~rt MR 61 Rev. dA08 TRAUMA HISTORY AND PHYSICAL EDCAMINATICEN ca:y - Treuna serv~cas -~A~11P!~!-~!!p~ga!!m!i ~m ~~II! Facility: HMC i'a~c i'':3 of 1n3 rauen> Name: ~Hri~.r~,rvu, i ..:, .::.s Date of Birth: 10/3/2005 ,. ~,,,~~;e...36 '..(F, ••~ ~• nle' ;:.'yi.L' 4~,"n : sM ~t.1C .!~!~ '91n ah {~ i}R. AM+~~ ~~~ ~ ~'' 1 ( ,V V ~~ LEGEND: i~acerartiorr 2-fraClure 3-abradon 4--COnlU610r1 ~ ? ~ ~~ ~( itii~l i~i~Elraili' `- :'' -~ ,. a Gls:gorr Coma Seale Trauma Score Cranial Nerves: ~a > Sp(nal Cord In )u r c 1-7 ~,°~°,N"° Ram. Rats NIOtOr: ~ '~ (- - ~ 2 - Open m Paler 3-Open fo CommardlVoice 88P 0- D 0 T ~- 8i~ane°us YlAN Rea/enae - 0 1- i-9 1 - 0-09 Sensory: Pinprick 1~ 1.12 a - i°o~arMepriu~as b ~ a -25355 3 -;~sD Proprloception •~o i C ao~sdCanswe4~bk Palo 4 -10.24 4 ->90 !}TR'5 ~AIerUOriemedllyderacts YrRec aoq bra L t-5 a p 1-Bone 2 - Decerebrate 0 - 3-4 1 •5-7 3 - DernrtleaU 1- Ylf~hdrawa 2.8-1 D ` to to S vocalizes Pain ~ pbeys 3 -11-13 4 -14-15 SB Toral: / 7olal: ~~~'~' - = ~ - - - ~ PT: Troponin: U/A: ,~ I / P'TT: Myoglot>in: _ ~•Y S3 ZaY ~-~-{ I T:Bili: CPK: Drug Sereen: r' \\ ALT: Amylase: ABG: ~ ! A ALP: ICa: ETOH: ECG: TEE: ~! BHCG: )f`R~ .. CSR: C ~ Pelvis: ~ I'{ CT Scans: Head: Rasd: -; CSplne: Lat ExtremlUes:~„,~ J Abdomen;,~`,1k AP o r ~~'iti ~ Others: ~. Odorrtoid Anzio: .I T 8 L S Ines: • Ile UIS•: ,., Prsblagt list: - •t. •Attandinp No~~plan: . e.a e..- , , ~V' C~.aD. ~ • ~~~5~ ` ~ ~ ~ ~i • 1 , C Attend' Sig r e ° MR 611 R~41lDa - Ori° -Chart -~ ~ ~ ~ y TRAUMA HISTORY AND PHYSICAL EXAMINATION '~ COPS'- 'Traumc Re~e'~e Faciltty: HMC Page 124 of 143 Patient Name: GA'riL';iJi), ~hlr~i;Hk J Date of Birth: 10/3/2005 • r~ lJ • • Facility: NMC PENNSTATE HERSHEY S~ersheY ORTHOPAEDIC TRAUMA ASSESSMENT FIN: 10506936 '~~~~~~~~ • TraRna ~ E~ ~ 75oAe3 6 EIIDBAEd1T Bt{ETT I ~' IOSOEp3B , ~Y: 280BD (0/03/2005 'AIBS 7232.1 VI~YT Cb~TF.: n3/n-;~~,p History of Inju ~ ~ Attending on Call: Consult Date: O Aate of Injury: ~ Consuk Tme: f Ci A i n nt Past edical st unknown Addictions: motor vehicle ^ hypertension ^ hepatic disease ^ toba ~ ^ motorcyde ^ coronary artery disease ^ HIV smoke~dL ^ pedestrian struck ^ peripheral vscular disease D hepatitis B . S chew O fall ^ . congestive heart failure ^ cancer ^ alcohol ^ industrial ^ diabetes ^ stroke ^ narcotics ^ farm O COPD ^ spinal cord injury ^ unknown ^ assault O asthma ^ ^ other ^ gunshot ^ artriai fibrilfatiarr ^ non-~embulator ^ other ^ renal failure O anticoaguleted . Open Left Rght 1. ^ ~ ^ 3. '^ O ^ 4. ~ D 0 ^ 5. ~ ^ ^ ^ 6. ^ ^ ^ ~~ O O ^ 8. ~ ^ ^ ^ 9. ^ ^ D 10. ~ ^ ^ ^ ,,. ^ ^ ^ 12. ~ ^ ^ ^ Residerril commen L f~ ~ ~~~4~C. 5 Cl~u /l~/ ~~ rc .e -c ~ ~ C w1L ~ ~~ ~$ ul L 3 ~ /` ~' Attending summary and plan: Exnactsd oetiod of non~re~ght bearing: right leg left leg right arm left arm 6 weeks ^ ~ ^ ^ ~" 12 weeks ^ ^ ^ ~ , ~ , , , Cervical: ^ 6 wks ^ 12 wks 'TLSO: ^ 6 wks ~ ~ 72 vks Resident signatur I' ~~~- ` ~ ~ " ~ , Attending signature: date: ~ tir`.re: ' ; ~ ' ~hhUPM ...~ ~ , n~K eia Nage ~ orz e/uts ORTHOPAEDIC TRAUMA ASSESSMENT 'TLSO = TFiota~:-lumbar-saixal orthisis Pae i ?'i nt .~i3 __ ranent Name: uHn~~NV, i .;,s ci c: ; J _ Date of Birth: 10/3/2005 ~" ~, ~. , I 7 r~~~. .- r,`, ii~~~ iris. Oithopedtc Trauma Physical Examination RIGHT J / ~~ ~/( li\ .t 0 ~~-~' eaclc PHYSICAL EXAiill NL A@a. jyje 6 L j3 L g ~ L Neck ~~ ~ ^ ^ PelviB ~ . ~' Spine ~ ~ O ^ Hip ~- ~- Clavide ~ ^ ~ Thigh ~} ~' Shoulder ~" ^ ^ Knee ~- Arrr1 ^ ^ - Calf -~ Eltww Forearm ~ ~ ^ ^ ~~ Wrist ~" ~- ^ ^ Hand !~ ~ ^ ^ VASCULwR EXAM EXTREA~IETIES RAO ULN FEM POP DP PT NEUROLOCi1CAL EXAM °~ oZ t OZ~ UPPER EXTREMITY t~ Motor L dN~id ~p fl~ ~~ 5 p S R ~j fl" 5ensary R r~ ~ CB C7 ~ T~ L i~~yLe~ n . LOWER EXTREMITY Motor R pappa Next quads hams tlb ext haq long gastroc L ~ ~ ~~ ~ ~' 5er~sory R /~ L3 L4 L5 Si L r~ ~;~ Rectal: hyper noun hypo abse~rt 1T ~.S Bulbocav: hyper none hypo absent X-RAYS IBAl~IA BE BIE$ . AP j6AI GSpine D O T Spine ^ ^ LS-Spilte ^ ^ Pelvis p P08 IYf 6 ^ odon ^ ^ ^ ^ ^ ^ ^ ^ MR 874 Page 2 of 2 5/08 Facility: HMC ORTHOPAEDIC TRAUMA ASSE33MENT ~-7. .. .._ ~_._ ! LJ ~'iEiitt IrrfUly Aortic dissect. ~ Pneumothorax ~ Splenic Injury 7 Hepatic injury ~ Renal iryury ~ Bowe1 injury ~ Bladder rupture ABN ~ is ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ °~i• ~~~ ~J; ,~~ Additional Studies neeed~ ~,~ ~. 4 ~ f f 2 ~----1 ;~,,, ~I 13. 4. ~ hA' ., 5. ` 6, • ,. , ~. ~~~ Page 126 of 143 rauern ivame. ~a~rrsu-tivu, I h.; :~ ii : J Date of Blrth: 1013/2005 PENNSTATE HERSHEY 1~ NLiXt~n ~., ~Ie~he~ Medical Center PGY =Post GreduNe Year MR 414 Rw. 1!06 Pays 1 of 2 IIII~N~~I~II~N~~I~ TRAUMA TEAM SIGN-IN SHEET ru~E: Taaula, ~soee3e X44: 7508A3A M$N: tOSOF.!'36 tit7: UEHLY'tY1 CriNYB'i'tD EeJdi: 411323 DOB I 01/01J190D I VISIT MTE: 04/24!2010 ELF PAY I 6~I~~~~INI~1 __ __ _ _ ..-__~ Date TRAUMA LEVEL 1 Trauma Standby paged at hrs TRAUMA NUMBER 2 3 Trauma Response paged at hrs - a ~iRESPA~ISE.:'i?: .MEM~I~ . i '~~'. ?c~ N r NAI~1~ , 7 ~~ •TI11~SgFAfTiyy~~l• .%- S ED Attendin Trauma Attendin Trauma Team Leader PGY4/5 ~,..~..~ ~ - -L,,. Senior Trauma Resident PGY 415 Junior Trauma Resident PGY 213 Junior Trauma Resident PGY 213 Junior Trauma Resident PGY 1 Junior Trauma Resident PGY 1 ~. Eme en Med. Resident PGY 2/3 Eme en Med. Resident PGY 213 Eme n Med. Resident PGY 1 Trauma Ph ician Extender ' Trauma Ph ician Extender I Anesthesiol Attendin Anesthesiol Resident y~ Certified R istered Nurse Anesthetist Re irato Thera Radio) Attendin Radiot Resident Radi ra her #1 Di nostic Radi ra her #2 Dia nas#ic A Radi ra her C E n Medicine EMT Cha lain ~ OR Technician !Nurse Pediatric Critical Care Attendin Pediatric Critical Care Resident $f4.tn 1(,~,~ ~-. , Child Life S cialist ~ Trauma Coordinator /Case Manager s_ na.~ ~~SJN`!-~~ A~•1 ~GIII~,~ ~ _ ± y~' ~ a s.: ;l~E `~ ..%, . ~ « ~ • t . TIIBCY_~ ~'~~ . ., ~ ~# OrtFw edits P er 2002 , ~ , • Neurosur e P er 1001 ~ . Plastic Su ry ~~,~; "-" ~ ~ ENT ~ ' ~ ~ ~ ~< < ~ : TRAUMA TEAM SIGN-IN SHEET Original Copy~.i~t9di;k1 Records Pk1k Copy-Emergency Dept. YeNow Copy-YFaru,ta Services i Facility: HMC Page 127 of 143 r-auen~rvuine.~aY.F:"_~;:';:!, !IlitttlNJ Date of Blrth: 10/3/2005 ~ `~ PENNSTATE Ur-ln`~,f q4 '~~ Nfilton S~. H[ershey Medal Cutter C J • • ED TRAUTAA/RESUSCITATION FLOW SHEET/ORDER SHEET NAME: 7506638 rrr~ ~soe6ae' tiJB Ot/ay(y@@p 1tai7pATE: Od/::81~'t77U a~'~~I~~I~jl~.__ SELF PAY _~J J DATE TIMf R£SFONSE STAT PAGED ,~,~ RESPONSE LEVEL 1 3 AGE SEX.~_ WT TIME PTA RNED REPORT r p ~dM(.~ ~' ~ M p'i9tEdiLnc !~C IY1tI+t• c~ ~ ~ 3' AMB/1AEDIC!` ' - P BP GCS "'~~_`:. :ATT~N ~ G~< HELICOPTER ~n RR BAGGED ~ MEMBER TIME ON-SCENE INTERH05PfTAl ~ - OLLAR IDIiOWEL ROLL TRAUMA ATiENO. CHART, LABS ._ XR _ CT ~ // LONGBOARD/KED ED ATT f LOSS OF CONSCIQUSNESS: _NO _UNK !pYE~~P Mgl MAST ENTRAPPED: _NO ,UNKNOWN _YES AMIN SPLINT D• ' SELF EXTRICATED: YES NO ~ SR. MA RES- T. _ e v. t 'N~~'~~ ~•~~"~ fir. ~ .. ~- ~~ xw.- ° RESPiR~A ~ 1~S1 ~ , <<~ .r .. f - - RIER MVC _ EJECTED _ WINDSHIELD _ DAMAGE apONTANE00g pATE L _ _ „ PICI4IP ASSENGER ~ AG _ i FT _ BROKEN _ FRONT SEDATED _ PARALYTIC ASENi MP1t ~ TRUCK _ FRONT T ,_ ROLLOVER _ SPNIERED _ BACK D ~ 02 MASK LANIN BACK VAN ST WHEEL BENT ` _ BROADSIOED NONE X _. HEAVY - ~ CANNl11A LANIN _ _ _ PEOESTRUU9 _ BED OF ,_ ~ PICKUP _ UNKFIOWN _ UNKNOWN _ R _ L _ ASSISTED RATE ^ ~ ~~ MOTORCYCLE.-., BIGYCLf_ AN_ HELMET NONE- UNKNOWN- -AIRIIYAY(ORAUNASAL- fT _ GSW FALL CAUFNrI - ETT (ORAUNASAL) SIZE _ . BURN ^ • DRRNG ~ DROWNING ,,,, _ FARM _ INDUSTRIAL _ SPORT _ STA881HG _ OTHER - CRN~THYROtDOTDNIY TRACH S¢E ~:, IV GA~16E S1T~ SOL' AMT. INF. EMT? ~1 T~S S N MEOS LAST TETANUS . iY2 Y / N iF9 Y ! N ALLERGIES .~s1~I~$ . . IY(aII _ :. R:~IMIIR,Y V~ '1!~B~CDR~- _ ._r• .. .. fn ae a q CHE8T P AtD EN 8 Openhrp LABORED BREATH SOUNDS R IiEA~.T SOUNDS SOFT _ TENDER STABLE ResPmrse To r ~ Y YES PRESEMi ESENT NO RIGID YES NO UNSTABLE t t . _ PAID ABSENT _ _ MUFTLED _ _ ~ _ DISTENDED WHERE _ _ PRIAPISM ~ ~ l 6 5 1~N0 •_ YES CLEAR _ _ G LNG SCARS BL000 W ____ +l Coat V eA ~~ pIMINISHED _ BO SOUNDS _ 1'ES NO MEATUS Response rewords p 3 TUS PARADO CAL C E5 ND WHERE cane t t 0 _YES C~HE~SYMMETRICAL ~ _ _ DECREASED WHERE ~ ~/ YES YES _ NO best cammsna - - `"~:, . `~ •..a. ~... ~ [ tEIES ~~ R '-'~'~:.a :. ~';:? ~,. ~~ ~ .. ;: SKIN ~~ HE ~D EC :.: Mover Lodlres R~uy ~„~ ; s a ~~P LYSIS P SIA . P P PALF IWi AIR PATBtT ~ _ _ CYAN L TIC CO ~ _ O _ O MOTTLED COLD YE 0 JVO ro t t RL _ M015T _ TRACH MIO E ~ANOTIC ~ ToM Apgrmaamronocs 6CS poNOaolTnaUmsSoore ~~ ;, 71 : '+~t4 e _ V SIJL~A~I tr - ~ , a 3 _ . e y ° TIME TIME ~' 3 ~ 0 SERVICE CALLED ARRIVE ~ r ~ e iz SCALE (GCS) 8- 8 2 2 ORTHO 1. pPEN FA6CiUAE FECCHYMO6IS ~ ~ S z.MSPUTAnpN 1~S TN ND A--mlusar a C C ~ ` from ) 3 0 N ~~ 07 8.6 HO 4 6ER1RYITY - dINSNNI ` it L-LYSIIAn6N • /~ • . . . STAB YYOUNG 5 n { i 5-51761MC ~~• r r . lic r 89mm H PLASTICS . BURN 6 T-iENDERIFSS + i ' . . ~ - . P « , PW-PUNCTURE i ~ Pre6sure 50.75mn 2 ENT a. ~ ~ 4 ~,,, M m 1 T gam. FT ~ No OPHTH. Pr Reapirotory 10- 4 4 SC , Aeta ~ n. FIYPALEDO6JECi ~ B~.+min. Y 2 ~ ~ • ~ 1 1 • Herr r Toh{ Raubed Trctmr Score ~ ` c Original - Medical Record Yellow -Trauma Servbe Plnk - ED MR 6li0 i1?/!05 ED TRAUMAIRESUSCITATION FLOW SHEETIORdER SHEET -r r ~' V =aciilty: HMC Page 128 of 143 ratient tvame: UAFiUaiVO, I ;x~;ir;w .1 Date of Birth: 1013!2005 N.. ~ ~-, ..., , .; FIN: 10506936 • NEUROLQGIC EVALUA~IQ,N _ _ VITAL SIGNS ~~ ~. Ro TE of TEMP. Time Pupil Pupi! Time Wa-m "Pain Size React Motor function Cardiac ~ E?2 ~; !itrs ^cale L R L RA RL lA LL GCS R m P ,) R Sat a i / B.li. Ilsed _.., Adult NoM1 ~ i ~ C aaE,aoFCaNCEaN NEUROVASCULAR ASS~ SSAABNT ru~asssssEO TIME TEMPERATURE COLOR CAPILLARY REFlLL SENSATION MOVEMENT PULSE TOTALS ~ • ~, X-RAY Time C-Spine Lateral A/P Odontoid Swimmers CXR Pehtis Cystogram Exd'emitiea CT Cranial Abd omen Chest Other Anpiogram VENT S 11ME RA fl n L P UT ^ uA/ ^+TDx SeNT ' ' ` TIME URINE G ESIS RCT LET `~OT~'rIEr~S ~~~,~ TOTALS " ^'. IR;TAKF TQTAI_ I • ~~ ~ OUTPl1T TO?rtl. ~ ~ ~'' .. ...".. __..." __.... bs Facility: t-IMC Psao 129 of 143 Date of 8irth.~ 10/3/2005 nnrtrv: iSUG~;se FIB!: 1050693E ~~._ _. 1 ~ N SE'S NOTES INC~uiDES: 1. Assessment 4. Response ~ 2. Plan 5.Ongoing As~;seasment I ~~-,? _,~ _ '~,r,-.~, ,.. ~},, ., ~_ r.~, t ~a ,~_-~~ _. :, a ~ .,. -.,,-., !:3~~,(lterventjon.,, ,0¢?.,A.,~~~.51~9'11ti14~sJt'I~' 1 F _ • =. N E UF#QYASICULA[~A$SE$SNI E__NT -~.. TEMPERATURE COLBR u ~ ~ ry ~NEFlLL SEUSATI~I Iy0VEJ11EtlT PULSE W-Warm N-Normal R-Rapid N-Normal A-Active S-Strong C-Cool P•Pallor S-Sluggish T-Tingling W-Weak W-W~k CD-Cold F-Flushed A-Absent N&Numbness B-Paralysis A-Abserrt H-Hot C-Cyanotic P-Pain and A-Absent R-Regular 1-irregulaz 9RACELET LOCATIOf~R117653 BLOOD BAND-~~r ~/yll(di(~~ Doeumsnting Nurw: Support Nurxe: Q •~ r Physician Signature: -..,. - BVM =Bag Valve Mask ET = Endotracheal Tube ABD =Abdomen RL = ~ ~9 LL =Left Leg RA = RIpM Arm LA = Lett arm C. w i = ~ s,nesr r uoe RCT = Right Chest Tube PH = Pn:-hospital LOC = Level of ConsrJousness PMH =Past Medical History BH = Bair Hugger na =normal amanpm W =Weakness FP =Flaccid Paralysis R =Rigid DC8 = Decerebrate Posture DCT = Decortirste Posture RFACr1YnY: e • eridc F . Faed S . SluppisR D = Drlatel N - Nonn~diw ADMITTED TO ., u~ @ L`'/ 1`! V REPORT TO ll'YL~t ~~ N TIME OR NOTIFIED OR READY TO OR FAMILY NOTIFIED ® BY RELATIONSHIP C-SPINE CLEARED: YES 0 B R. C-COLLAR ON: E5 ^ NO ASPEN: ES ~ NO VALlb16LES: /PATIENT ^ SAFE ^ NONE ^ WJFAMILY ^ BELONGINGS FORM DONE ^ EXPIRED CORONER NOTIFlED ~ MATERIAL EVIDENCE TO POLICE: ^ YES ^ NO OFFlCER BADGE ~ • TRANSFERRED TO VIA 1.~~:7.: ,~LR..:;~~ ..,~~,~~ 2 3 4 5 6 7 8 g Facility: HMC Page 130 of 143 ralient Name: uftt;i.i-~r~u, ~ :: ,, i~ ~t; ~ Date of Birth: 10!312005 PENNSTATE HERSHEY Milton S. Hershey Medical Center PROGRESS REPORT MRN: 7506936 FIN: 10506°^Fi ...._. -- -~- I~~INY~®~I~ NAYE: (#4NlAND, TIMRA J 16TH: 7508Q3B 10506838 OOSM ffTJ: FJdv"~RCpiS' OtaETF 2005 oDe: 10/0. r."Dl:: ?8060 vlsrr nav¢: aaias;ao~o 3 ~: 7188 202.1 SEX: F N 7 F AY ~I~IIIIi~NR-. - --- SELF PAY -_---- ~_______.~ Dat /Time PROGR OTES: (Include Name, Tltle) 3 ~ • ~-~i s~ F-1r'ss my a 2~ ~~ ~ n cl , -~- ~ , ~ i _ ~ • j - ~In /' ~ /J /' 1G .1 • • 6~~ Ra e, s [ / /R/IlE6,~ ~ ~~QX rPXt S ~al~n AL' r k /1Dtl l~~ 1fo Du ~~iA~~l C ~ s e{ t p S Lt..B 3 G i ° Dy D~/-~lS. O ' f >ti G ~~ ~ t/SS. ' ~~ c~ ~ l r P y .~ WwS. ,, ,, _...- ~,, 4~ea/ zz ~• «~ ~~ __ ~ _ . < < MR 8 Rex 5108 Page 1 of 2 1:~ ~~~~ ~~_,~~ I~I~Y~~l PROGRESS REPORT , , , Facility: HMC Pag~a 1~1 of t43 Date of Birth: 10/3/2005 PROGaESS Ft~Pt~RT MRi~J:7;;:; .,:: FIN: 10560;'.?3F • • • • • Fac(lity: HMC Pa~a3 i':2 of 143 F'atlent Name: CaH1iLAIVU, I IAIitiH J Date of Binh: 10/3/2005 FIN: 10506936 PENNSTATE HERSHEY ~ ~~ ~Miltal S, Hershey R~a4at ~ :.:... Medx~l Cenleir I'rintod: Saturday AR 06, 2D10, 05:1 y Gyorfi, Jatiln-R • RM: 7232, 7MB3 GARLAND, TIARitA J 4 Y (DOB:IOl0ar2005) F MRN: 7506931 •~ Atleading: Fngb:xcht, Btar W Cade Blotto: None SpecJcd Reasat for Adtahtsioa: Norte Specified Service: 1'cds Surgery Allergies: NKA . ,. . Problems: None Specified Diagnosis: Cbsed [tacmre of the davicle B 10.Q0 : Facial laceration 873.40 ;Trauma -major - ' 'Isolation: Dkl: Advance Diet as Tdetattsl Inshuctiosu VTE Risk Score: 0 to f point -Low Risk 03/05110 19:01 Skle Risk Score: 28 Peripbetral: Left, Atdotatbini„ Vitals Teaap PuMe BP RR Sp02 F102 Date Wgicg) - VYt(ib) r-~ o3a6 oa:oo 36.7 log 2a - --..- o3ros Iso 33 03K3S 23:08 3~,~ 111 24 97 - ~ 03/05 _ l5A 33 03!05 20:49 120 11717'7 24 100 - 03105 IS.O 33 03/05 20:06 118 104/57 20 _-- - ?A W T;rnstc: 37.0 at 03103 20:49 36 lir Tbtatt: 37A at 03105 20:49 f l pttt ~ o3>.s o 3p-Ilp 210 llp-7a 330 24 Total 540 03184 ?a-3p 0 Vitslt Signs arc the hW S in the past 48 boors. 3p-1 Lp 0 Weights dispisy the last 5 within 7 days, ~ ?q Tofal 0 ImtialWl: 03!05 IS.Okg 331b f pttt~tn dalattoe 0 0 -- ISO 60 ... . 0 330 I50 390 ~-- 0 0 0 0 0 0 •-•- 0 D.•__ Arrive Lpatleat MetBptions: ta«pMne 0.7stng [V 4~ bacitracia topical(6ocitracin topics! 500 units/g ointment) One Time Mtdintlma in flee Past 36 hours: lappl topical bid _. Caa~oousLfbsitmt Actlve PRN lliedkatimu: Dextrose 596 with 0.9'b NaC1500 tnL + potassiam chloride S • acetamiaophrn (TYleoal) 200raB NO t141t tttEo SOOrnI.. I V Sn mUHR Laps: Ruahs-shown are i6r the past 12 hams - 03/05 2314 WBC (u) 5-9 MCV 792 Mono, Abs 0.3 Colar(u) YELLOW RBC (u) I-4 MCH 272 Ews, Abs 0.0 Appear (u) CLEAR Red Sub (u) NEGATIVE MCNC 34.3 M Basa, Ab6 0.0 (31u(u) NEGATIVE 03/05 1340 RDW 13.1 lmmatureGt'at-96 0 Bill (u) NEGATIVE Component RED CFi J C Pitt 294 lmmat Gran. Aix 0.0 Ktaanes TRACE # Units 0 MPV 9.7 RBC Morphology NORMAL SG 1.025 FxpiresatO600A 03/08/2010 Type ofDift: MANUAL Giu 92 Hgb (u) NItCiAT1VE ABO/Rh A POSITIVB Neut'J6 27 K 3.9 pli (u) 6.0 R Nnmber R t 17633 Lymph96 69 H Nor 141 Pros (u) NEGATIVE Antibody Scr NEGATIVE Maoo56 4 Pif 10,6 Urobili 0.2 WBC 6.4 Eoa96 0 INR 1.01 Nitrita(u) NEGATIVE RBC 4.23 Bato96 0 PIT 29 Leuk Est NIBGAT]VE Hgb 1 I .S Neut, Abs 2.3 ALT 37 Bact (u) MODERATE 1{ct 33.5 Lymph, Abs 5.8 Aatylasc 46 Notes: ~ : into-S o~ d.l ~.<~Fd~ ~ lain ..~ 1,_ t nor.- - - - ,.:... _ _ r .. /° Facility: HMC 3 - ., x ~~ ~, ~ ... ,~ 1 ~..0 '~~.o iG err ~ ,. •. L Anr't 9 ~ n M .krA~+)'ln~'1reo....-.7 f'~n~ 7- Lre-r~'7 ~ ~ -. , r ~ , 13ad of Report y ` ° F= ~ . MR 1172 I~ ~~~~~~ Signatote Da mte , ~,;~ ...:-t? P2~c 1~3n`. t43 i auc11L IvaIIIC. Bann L/-tIV V~ ~ Illnnh J Date of Birth: 10!3/2005 PENNSTATE HERSHEY Milton S. Hershey Medical Center PROGRESS REPORT ,; . ~: ; !, i~ic.i,;-,r;3~ c ~ n o t' '~4I-' ~ i ~~~hfi~~kl~~{~k~i ;,~~I~i~ HANE: (iARI./1JDt TIApRA.: F^?: 7508938 ' j i ,. .. ~A1: kt108FEG'::: 006: 1Q(OS1200;, ST 132 ' ~ : ~~e C O L ttFL'"~Y~ f'-,'~;,_,; i F y ~ pp ~~ jj pp~~ r ~ j ~~11~~1'fI~IN Pl __ .. _. ..___ _.._ .. __-~ Qate/Tlme PROGRESS NOTES: (Indude Name, Ttie) `3 ~ ~{~ ` +/y, / ~ _ ,~. pper~, ~ ( t R Wa~S ~V1n. ~~ C ~ ~~~ ~~'"~ - _ ~. J ~ ~ ~~ AA ~~.7'~(J ~~ /1~ J+T~ ~..7ti ° l~ Y ~____ ~.~4~ ~ Cam- n i ...r..1!' 1... ~, ~ ~ ~ r ~ ,. 1.,. , :.T~ a.a 1~; • n w.R s rte,-. sroa Pao. ~ of ~ ~~~~~ PROC3RE39 REPORT Facility: NMC Page 13~t of 1~3 Patient Name: GARLAND, t~l:=,nRA J Date of Birth: 10/3/2005 rr,.., PROGRE~a REP®R7' • CJ • • • Facility: HMC Page 135 of 143 MR a Rav. SIDS Papa z of z PROGRESS REPORT < < ~ ~. ratient Name: ~i .. ,; ~ .. , , ....., . Date of Birth: 10!3!2005 PENNSTATE HERSHEY ~ f111NMI~NI~~I~MI~I Mt+SE 4~9A1t~10, itARRA .J Milton S. Hershey nos o1o~t2aos~; ~ IsrTDATE: U3/(IS/z01~ Medical Center ~N~, ~~ P232-1 SELF PAY ..ii~~.~i ~t~~i-- -..- -. FINAL NURSING PROGRESS NOTE C. ~~ • • Discharge Summary {may be done up to 24 hours prior to discharge) gate Initials Course of hospitalization: (may write "concru with Day of Discharge Fomt'~ `` ~ ~, I /1 ~- lU c.-~+ ~ .n S ~u Resolution/Status ofeach robbm on the problem list: 1 ~ c,~~ ~~ ~ ~ - 1~'~ , ~n iC~~ Q i n o~ 9 Q . S ~ ~ P n~ r~ ~D I o ! ~-e ~~ 2 ~ r a s-~~~~5 ~b 5 ~~ ~ Z.,v~ - ~-~. ~~~ ~ 1 ~ ~~t~S s~~lo~e ~.n~~ J'Pw-.~~I~~~1~ a ~C , ~ . ie ~~~ ~, ,~~~b ~~~ s p ~~ :~~~r~s5 ~ ~~ ~ ~ ~~ ~o Discharge Checklist ..........explain any "no"answer below 1. Physiaan order written for discharge.............. ........................................... 0 Yes O No 2. All invasive lines and tubes that are not needed for home care are removed...... ®Yes O No 3. Medications brought from home are returned ............................................ O Yes O No ANA 4. Prescriptions given to patient or family ....................................................... ®-Yes O No O NA 5. Personal bebngings taken ......................................................................... des O No O NA (Bathroom, closet, cabinet, bedside stand, over-bed table checked) 6. Copy of Day of Discharge form given to patient or family .......................:.. ~1(es O No O NA 1 7. Copy of patient education instructions or materials given b patient or family....... ,~ Yes O No O NA ' t3. Follow-up a~ointrnent scheduled or discussed with patient ..................... ~tYes O No O NA 9, is patient weak or unable to walk without assistance? ............................... O Yes ~ No O NA If yes, stab member accompanied patient to vehicle ................................. O Yes O No O NA 10. Discha a comrersation with dent includes the folk>Iwi r9 Pa n9 Points............ ?Yes Cs t.F~ O NCI ' ' ~ , • Strive for care • surve In the mall • Pu se b lm ve service and rewaM satf F.xplanatbn for "no"answers: ~ ~ ~ `< - ' ~~ ~ ~ L t ' ~" 4 t l 1 ~ -[ l + ... • . t~ you Rav iros Pay. t of ~ ! JPPII~~~I~/ h (t!~p! l~I~ P~1I'IF~! ~IIP~ }Pn~ c. Facility: HMC FINAL NURSING PRQGRESS NOTE PagQ 136 of 143 F'dTletli IVar17P.: laNIiLAIVU, I IFFiNfl J Date of Birth: 10!312005 • • • PENNSTATE HERSHEY ~M~~~^i^lt~~o.^n^'SnH~~e, rshey 1r1RllCr~ l_.Glltet PLAN OF CARE o~c ~ J FIJI: 10506936 I~I~II~~~~~~~ MANE: GARt.AND ~ TiAFRA J 1Hp; TSOti93e E~ ~ETT EN D f 1i08p: tU505s.s AT~E: 03IDG12D9V T O p !e ~ p pg ~ TIIB9 2"3'2-1 ~ p(' - -- , V28I BEX: F PAY EST ~.os , , ACTUAL LF 1AY 0 Los Ili~{Il~lq!~!.I.a.. -. % SELF ____ - ._ _--__..-- -- ~ ~ S ATTEMWG L= ~ y~~~"~ 4 -. F .PREFEIYiEDN7WE:... 1,~~1~(.~. '~.Vr~ .r ' ~ - ~ ' ,;~ - . ___ i/~UJ{ - i RESIDENT . , nn .-~_ , ~AfIE.~ ADM.OATE _ gQQyf__o1~. •. C ~ _ ~~ ` V PRI~AARY NURSE --. ADMISSION: - !~.e~ t,dCh,~~r ATTH~OING NURSE -. -- , . NUR6ElXJNSi1LTS NURSEt?DNSUI]S - - DlAQNO$IS 1. ~. .-" _ ^, SOGIALSERVIDE _ ~ 2 __ .- _...~..-_ _.~_ .. -..-. 3 4. DATE - - MNASIVE PROCEDURES ADYANCE OIRECTNE YES ~ NO CODE BLUE STATUS - - - - CONDIITON - - - ~. _. - ~Ak1Ff1OES - . _ .. -..----- .. .c - a • Problem UW Expected Outcomes Dab hddele . '~"'~ . DaQe. Y3tisb ~ ~- o ~ o ~o.a h rn ~ , - ._ z ~,c'oS S b'.~ R ~" Low. ~5.4~3~or•.~ w~~~ b wNL ev~t°~~ Rot. ~~ ~ = o ~j ~ i` ~h o fir; C.• .. 5 6 7 e ,. ~ , , ~~ DISCHARGE PLAN: ^ Home ^ Nursing Home ^ Home with Assistance ^ Unable ti0 determine on admission alarm m faro Re,Aewri wnh Pa(~~N/SigNrkaN Otl»r: Date ~ Sip~shi~ , 3~ v ^ Other. Explain ~ ~ ~ ` ~,~~ ...., a. ~ .+~. ~ tea, «z PLAN OF CARE •. ~~ F= .` FacIIRy: HMC Page 137 of 143 rnuent rvan!e. Bann! r.r!t.~, i !r+nnn ~ n- ; ~f Fifrtn: 1o~?,2n~;:; • ~~'%-. . ' r ' ' ' ~ t l r; -rJ 7 . ~ ff T ._. _,_. ~.~ ~~ ~ ~,~ ,,,, , <<,~,t. :,,., ,,,~~ Facili4y: HMC • • • • rage 13ti of 143 raueni fVdflle. laHfS l3iIVU, I Ifi F51'{H J Date of Birth: 10/3/2005 PENNSTATE HERSHEY Milton S. Hershey Medical Center TRAUMA ANESTHESIA CONSULT tvfi~i.: /oU6~:i6 FIN: 10506936 ~~~~~~~~~~~ FfAAIE: TRAUAa, ~soeo3e AWN: )608B3e ~~. DEFI.ITCt1 QIAI&TO 008m: 105081138 Amt: 48325 1xte: otrotrteou ~~: Ettttt ~+rslTaart:: o¢r2¢/~os sEx • u ~~~ r ~`r.F r~r Date / H t Time [ S W t Sex Consulted by Emergency Department Dr. Histo P6 sits] Ezam Ascesament & Plaa CC: General App Assessment: ~MVC elted Unbelted V~ta1 ~j~~y~:~2 (~~~0 ASAPS _~E ^ Fall • ~Cf'a' ~~ BP ?~ T Pulse (~(~ Injluies C.1:Ps- rtrw;, A,MI.J~ ^ MCC ~ SAO, CX.? Temp -7~ . ^ ~~ Glasgow Coma Scale HPI: Neuro: Time of Incident: Inert y~ ~j~~• ~'w[.nl u-C_._ Cervical Cellar in place ^ ~ n~ Level of Pain (l -101, ^ ~ ^ Di}l'icult Mechanism of Injury: ~ ^ Location: R 5~:s HLENT~ VeatBation: Function impairment: Adequate spontaneous Loss of~onsciousness ~: ^ Needs Mechanical Vent M t/i~• Teeth ~khC,~ ~~ P Hz: Airway: Malampati Scare~~ Blood Loss History obtaiacd from EMS Pupils: I ^ Shock Grade 1 Z 3 4 O Allergies A]D~ Size R ~f Z L 3 2 React R- ~_ L / 2 1 <750mL, 15°/. volume 2 = 750-I SOOtni., 15-30°/. vohtme ^ Dru s C est: 3 = 1500-2000mL, 30-40°h vofime ~„~ Clear to auscultation 4 = 2000-2500mL, 40-SOYo volume ~ Trachea midline D Labored breathing Aaestietic Plan: ^ Medical w),cs Tt D ~ Discussed earo with trauma team ~ Icader O Surgical rJottilG Hirt: l] Reviewed x-rays Regular rate Bt rhythm ^ Reviewed laboratory results ^ Murmur RO : p~~ tell O Meets criteria for immediate Y Diabetes D Imdudiom & Incubation Y Chest Paim/Chest Pressure p o Accompany to CT Scsn Y Short of Hreach/Respdratory Distress ^ Accompany to OR Abdomen: / N Diaziness Bcnign d Analgesia/Sedation / N Nausea/Vomiting D Tender / N ~~~ Bowel sounds D Monitoring / Deformity D Ot D Other O All other systems reviewed negative Extremities: ~o further intervention S No apparent fx -- Y/ Tobacco D Qr .TRs CAR S'e-~* C Y E101~ Y Drugs GU: ~ CpQ ~`eAt i~ei~h+'^ •'r ~ F y History: ^ Foley , Non-Contrrbnting ^ - - . ' ' _ • ` ~+I saw and evaluated the patient-and agree Atxeading Sigaeture: ~~"`~~` 'O ~ ~~© . with the rtasident's plan as written. Date: ` ' ` Time: p I personally performed the evaluation. xeaiaent/CRNASig.stare: --• _# Q~sf~ O Tb.tc.•~ 'I~ MR 1153 Rev 9/09NNPagge 1 of 1 TRAUMA ANESTHESIA CONSULT ` ` `~ ` ~~~ ~ ~~ ~ fll~ III ~I Green Copy-Medial Recant ~It1e Copy-Bilfin0 41 Facility: HMC Fwg;; 1:'J of 143 Date of Birth' 10/3/2005 y V FIN: 10506936 PENNSTATE HERSHEY ~ Milton S. Hershey ®Medical Center CONSULTATION REPORT __ (3r TO: DR. DEPA MENT DATE/TIME OF REQUEST: REQUESTING PHYSICIAN'S NAME: O URGENT O ROUTINE MEDICAL REASON FOR THE CONSULTATION: PROVISIONAL DIAGN051S: CONSULTATION REPORT BY TEACHING PHYSICIAN: (FELLOWS, RESIDENTS, STUDENTS, ANCILLARY STAFF USE REVERSE SIDE) The teaching physician must 1) Document CC, 20 eaher documerd HPI, PMFSH and ROS or indicate review of those documented on reverse side by filling in the cirde (O) below, 3) personally perform and doarment key portions of the pE, d) stems the diniCel impression or diegnosis(es), aM ind~ate the Plan of Care. • • 31~j~~ ~~ ~~ ~ , _~ '..~ ; O PMFSH, ROS and HPl on reverse side have been reviewed by Teaching Physician. , CONSULTANT: ~ ' ' • (LEACHING PHYSICIAN(! Name (print) 5gneture tote ~ ~ - T}gje~ trnr. ~~ ~ i ~ MR 14 Rev. 510E Page 1 of 2 ~~~~~~~~~~~ CONSULTATION REPORT ~ ~ ' ' ' ` i ~ .. „ `,~„` Facllfty: HMC Page 1Q0 a- 1~3 ratient Name: CaAHLANU, I ~"-; ;i?:': ~> Date of Birth: 10/3/2005 Pv:i,i:. , ,.... ,v FIN: 10506936 ~ . , . ~. _ r<tao~ ~i~; -~J,.,~n , i~~IIII~IMIi`~~I~~I~~~lifd _. Jd 7U/€lal:'af: .~ , Y`Y h i :: ~v'r;~5l.'u"(; LOC 7q$8 r2d2-7 X: F N SFLF PAY 5Et.F PAY . ~t~li~l1~INIIW FELI-OW OR RESIDENT: Document Chief Complaint (CC) and History of Present Illness (HPI). Perform add docurimenC Pfiysicaf ' Gram (PE). Document Plan o(Care and relevant diagrwstic test re~lla. STUDENT OR ANCILLARY STAFF: Dowment Patient IdentHication (ID1, Past Medical History (PMH), Family History (FHj, Social History (SH), and Review Of Symptoms (ROS). 1~ PT- ~ 70 ~ ~ MvR ~ ~ ~~.~ L~,~ ~ s ~~ laL Ad~uc.~-.aF -tom b v~' >~+ t (~ v ~ 1 „~ , l,~ 1 1~c~~-.t,~ ~ c.~'~ ~s ~t L) , ~ ~t,.J~-- / l ~., j S u r~_ f~ r ~~t' ~ v Y- ~ ai ~ ~ R-C'i G GvY. b ~~~ ~ O G V 1 c~1/~- G ° mP / ~. ~ t''~(S a°~3~ S -7 3 U ,~ pU P' I s l ~ r~ ~ ,~ • ~~ ~~ • k ~'~" ~' {~ C ~M ~ ( V/N L -_r~;S I ~~+s ~ 6 J~ ~~,~ ~ // wNL ~~ • -l~v~r' Y1 i ~C f ~- 5 ~ y .tA.C +- 1 . / . ~ C r, r n~,cc.Q ,~"br'61 S1 ~r,s , V" i ~! ~ ~ I~ V ' ~~ ~~ ,0 . ~~l . , ~ . ,5s~ ~ ,. Name (print) Title ~ Signature Dace. , ^ ^ F 1 ~1 ~~ ,~`~ MR 11 Rev. S/Oti Paps Z of Z , ~~ •CONSIi TATION REPORT ~ ~ ~' • .~ _ ('`~ A. . ~ ,l' , 1 ~ ~ '! ( A.o s~ r I. ~ ~ r ~l _ /' ~ . !9~ f CIA ,, !:~ r _.~___.__.. _--____ Facility: HMC i'~gc 1 ~'i of t ~3 raven: rvame. ~anrsl.rrvv, I utnnr..! Date of Birth: 10/3/2005 r--. r _ i>~-:~~STn~-r_- ~ .--- -- -- - ,IRRI~I~~plllll~~II~I~pI!II~~III!r'~' Mitten S. Hershep ?~4e~ic:a.i Ceni:er COr.rf 1?(: i 7i 1hrUT4i GsiC%uiU - 1 7~d: 4G v ,__., _-______-,_ -.~~.__._ _-. LO~Ca ~J~6111®00 9I~SII uQATE:: 04l2412UiU CONSULTATION REPORT IN i F PAY 6ELF PAY 11~11~~11119 . .._. -----~ - - .; TG: DR Q~PtiF;TM~IV7: ~ UF:TuTIMc O"r F(EOUSST McG,hn d ~ LQrLV!-i.9~~f1~'Lj I ~~y~lO X90 `~ Ri_UUESTIIV~~ P'rll':>ICIAh''S NAI+A>v: ~NF~82EZy7" _- O U'=t~3~n.T ,~ ROU T uV~ - 1vIEUICAL ~i=ASUIV fQ~t Trl~ CONSULTkTIOIV: r9urh~~ L~?~r ia~! , PFIOVI510NAL DLAGlVr.;;,lS: C;:~Iv5ULTATION R=PGPT BY T~ACI-IIIJG Pi-!YSI~~I.ti1\I: (:___~! OwS, R=SID_NT~, ; 7UDeNT£, ANCI:.J+RI' STAFF L'S_ R:VcR5_ SID:J The 1 ohvsiclari must i i Uogirnenf i';C. 2) eirhm docurtirn; NPi, PNi=SH and fly. ar itltli~te rEw:ew of those documented on reverse side by IiHing in Ih0 circle (;~) belan~, 3) persnna6y phn,mr, ano no:-omen: key porlinns of Ihs: P_, 4) stair the clini: al impression o' diagnoss(esl. antl Intlical? the °lan of (;are. ~~ ~ ~ Y~ 1~"` J .. ~ 4 ~ C tl'K~ i I 111 - N-~v rM! ~~.~ ~1~, .~6G~ ~~ ~„o~~ ~` ~ ~~ ~ yQ ~ f,>;. ~r • t ~I+nFSH, HOS and H?I n raverse side/have; bast rsviswsd CONSULTANT: db., M~G~M MI (%=ACHING PHYSICIAN) eme (winU MR 1'i Re~~. ;2196 CUhSULTp.TIDN ~~ ~, ' ~~ , C Physician. ~ ~ « e ' ' ~' ' (' ~Oyr~ u -z-r-- ere ~ ~ Tirne ~cc,i' Facility: HMC Page 142 of 143 -anentntame:uNt-ciruvu, i~;,;;nH3 Date of Birth: 10!312005 FIN: 10506936 CdhrSUL7ATI;Jf~! R.?d~T FELLGVd OR RE51DE1~'T: Gocumsnl Chis1 %omolairu (GC) and History of °resent IWie55 (i•IPI). Fertam7 and ao~umens Physi~a• =zam (P~). Gocumenl Pian of Cere and relevarn diagnostic lest rasuiis STUD=IJT OR ANCILLARY STAFF: Go~menl '-aliant.ldentriicaiion (ID), Past AAeacel History {PhAH), =amity History (FFq, So: ial NiSlory fSH), end Review OR Syslerrts (ROS). , H~sTO>iti+: ~fya• ~ ~P P~'*~ ~ avg. fa-c~;Firrr ab~ace 8~(ab~ar/ ~oLc ku- ic~{- w,acv~gv.. ~-~~b~cG~ se.~; i LOC Lycs _no ~Vunloaown)/ AMNESIA (-Yes _no 'L4i-l:nown) . pIPLUPIA (,~~~es -Denies ~Gttl:nown) NALOCCLl:SION (^yesldenies^uni`nown) IviI.DS' .4LLERGIrti'S: ~ O~IwL l~Jd't~~~ r PSxHx: ~ ~ G~~C~. ~. PL-: GCS: ~~ I~C,,~+_iniuba>:ed~para)y~ :d EAI:S ~/ 1% - maswid (~~~stable: _ unstable) piartt, sac, T7vi, mid ear (~ormal ~ abnorma( ) L - mastoid f '>5'Eable, -unstable ) oitula, sac, i M, mid ear ! orma) _ abnormal j Ocher OT.23iTS (_ taoi_, Ittcstablr. } EZ'ES ~Lerrla L. - (, OMi _other) fryids.twr° _ d7.l~net.2r ~ Fri NUSL• Hasa! bones rS _/stabic unsKabi~ j . septum (?Stable _ hemazoma) MIAFACE (~ab a unstable) 1tiANII)ILLI; (~ aol: -unstable ) MOLITEilOP Teeth (±~intac, stable unstable) Tongae (/i anal _abnorrna() Palate ( ~fiormal -abnormal ) NECK f ±~-cod-ar ) Trachea (_ tdiin: _ stable _ erenitus ~ CIS II XD (_vl~orrnai abnormal ) 7' N) LACER.A.TI'Uf+t6 (sue diae<+ram) PLAIN FILMS (-none -normal _abnormalj CT SCAHS(_none_normal s.etKnormalj 17ra~rve ~~t~rrrz Name (print) u fey. e. ~ s~ /~{ vR~ ~ ~:t~ -..s1 ~.~ l~~wi GGd`Y~ o ._.. ~~ l ~ _ " I " r ` ~ ' M 7 v ~.t~.i , ~ - W' v C ~ ' f ~ ~..w-v a s.- rt.,r.~ c ;~ stk,,,,,, i ' ~, ~ ~ r~~ , [~ i`I'w r tf y D't 0 - Nr~y ~ , ~ i ~/,.2, 3 +5fj p ` 20 c1'~ Title ignature Date i ime cont~t.,t .T~tTION ~=F~tJRT f `' '` 7 ct,~.~, ~ , Facility: I~MC Page 143 of 143 EXHIBIT "5" PENNSTATE HERSHE~f Milton S. Hersi~~y A~ed~cal Center Patient Name: GARLAND, TIARRA J MRN: 7506936 Penn State Hershey Tel: (717) 531-8055 Milton S. Hershey Medical Center Health Information Services, HU24 500 University Drive P.O. Box 850 Hershey, PA 17033-0850 Visit Number: 14176746 Date of Birth: 10/3/2005 Visit Type: Clinic Patient Location: ENT1 Patient Gender: Female Oufpafienf Note RESULT STATUS: Final DOCUMENT SUBJECT: ELECTRONICALLY SIGNED BY: Gddenberg,David {417/2010 08:39 EDT); Kugler,Kathryn E (3/1512010 08:03 EDT) OUTPATIENT NOTE Name: GARLAND, TIARRA J HMC Number: 7506936 DOB: 10/03/2005 Date of Service: 0 311 212 01 0 I saw in Outpatient Otolaryngology Clinic today, March 12, 2010, Ms. Tiarra Garland for followup of her Vauma. She was in a motor vehicle accident on March 6, 2010 and she sustained a laceration io her forehead. She has been doing quite well at home. Her mother states she is eating and drinking well, running around, and playing normally. She is wearing a sling for a left davicle fracture. Her parents deny any other medical problems. She has never had surgery. Medications are Keflex and Tylenol With Codeine. SOCIAL HISTORY: She lives with her mom, 2 sisters, and brother. Nobody in the home smokes. She is not exposed to smoke. Family history is significant for cancer, otherwise negative. Review of systems is negative per patient mother reporting. On exam, Tiarra is a pleasant female in no acute distress. Her skin laceration has some crusting that was deaned off with peroxide and water. The incision appears very well healed. Her sutures were removed today with a nice appearing healing, although she was very distraught during this process. ASSESSMENT AND PLAN: Forehead laceration. There is still quite a bit of cxusting going on. I would like to see her bads io assess healing in about 1 month, just a quids visit to see how they are doing with scarring. I have reviewed with her mother to avoid any sunlight exposure, as this would darken the scar. She should use peroxide and water to dean until the crusting is completed and then also place Vaseline or badtradn over it. Once the crusting is done, she may use a scar cream or gel to help minimize the appearance of the scars. 411206 Date/Time Printed: 2/28/2012 12:46 EST Page 1 of 8 Printed By: Bender,Sylvia R PENNS fATE HERSHE~f i~11V~ilton ~. Her:~hcy iVled~ .cal Center Patient Name: GARLAND, TIARRA J MRN 7506936 .........................._.........._....._....._......_.__......_.__.__...... Outpatient Note..._.....___......_._...__...._.._.__._.__....._._._._._....____.____.._._... ; Electronic Signature on Fife CC: J Lynn Hoffman, MD 804 Belvedere Street Carksle PA 170!3 CC: Johnathan D McGinn, MD Department of Surgery Penn State Milton S. Hershey Medical Center PO Box 850 Hershey PA 17C33 Electronically Reviewed/Signed by.' Kathryn E Kugler, PA-C Author Signature Dt/Tm:15.03.2010 08:03 AM Otolaryngology -Head and Neck Surgery Penn State Milton S. Hershey Medical Center PO Box 850, MC NU25, Hershey, PA 17033 (717) 531-6822 EJectronica!!y Reviewed/Signed by: David Goldenberg, MDCosigner Signature Dt/Tm: 07.04.2010 08:39 AM Associate Prolfassor of Surgery Director, Nead tx Neck Surgery Penn State Miltc,n S. Hershey Medical Center PO Box 850, HC~91, Hershey, PA 77033 (717J 531-8945 KEK /CO DD: 03/12/10 DT.' 03/13/10 08.'51 DatelTime Printed: 2/28/2012 12:46 EST Page 2 of 8 Printed By: Bender,Sylvia R Patient Name: GARLAND, TIARRA J Date of Binh: 1 01312 0 0 5 * Final MRN: 7506936 FIN: 14176746 PENNSTATE HERSHEY I~~~Nr~~~^ Milton S. Hershey ~s°, TtaiAa J ~ :?~ e Mcxlic;al Center s a e °bo 0~'0 °~"~~ ~~, 1~1?67oF °®;?~° ;~ : 5 roc: tern , : ~~,2,20,0 sex: F ~~ Pwoi carer oa A ~ PROGRESS REPORT 11f~1 ~I 1~1i~1A . --- - Oate/Time pROGRhSS NOTES: (InGutie Name. Title) _- • • tilts 61bvtltllifOt Paar 1 of 2 ~~~n~~~ FaciNty: Hospital Based Offtices PROGRESS REPORT Page 3 of 8 Patient Name: GARLAND, TIARRA J Date of Birth: 1 01312 0 0 5 • Final " PROGRESS REPORT YR 6 Rev. 5.rots Page 2 of 2 PROGRESS REPORT =acifty: Hospital Based Offices MRN: 7506936 FIN: 14176746 t~ .. • • Page 4 of 8 Patient Name: GARLAND, TIARRA J Date of Birth: 1013!2005 "Final PENNSTATE HERSHEY Milton S. HeLStiey lbtedical Center DMSION OF OTOLARYNGOI HEAD AND' NECK SURGERY MRN: 7506936 FIN: 14176746 It~MI~iIM1~IIN~I~UI fM11E: GARLAND, 7IARRA J IfRO: 7508936 1a1787a6 OOSF: pD: tiOLDEN8ER6 DAVID DOB= 1Of03i2005 ~: 25917 Y1SIT WTE: 03/12f2010 l1C: ENTt l SEX: F ~ . 11f~~r~~~-'€~LTN PLA/01 GOPAY 00 ^,' 11 N .•:x. ~ ... Pti.-wu ~ +.., n.. , ..::v..; . _ s <- .M;.:~ ..,,,. a-. -.a~, •. _ li~'O `;F.iiicle ~.If.''ias'a t9tlld'iils~Ler .°. ~}~,~ys~4 .z;....:; ~:.~.;; 3...:,.,:..:•; <;-;t:. ~ p fitieet~ta foe.fho parettt~ C :S~G~I: 'V~CiC 1 ~ ~ ~'i' ~ ~ ~ r . - . ., _ ~(,J ~ aFaats4l ~ / icd /, Ihvarced /Widowed .. ; f } ta< I'aricnt's Abe ° • < /~~~ r ~~y~~~~~ M nor ~ Cfiildr ~ - e :. a~.: <~ • # [Il lJ~1AQCl1 tf ~. .rtY.. 1 Wilco 1Fvieis hotlsebbld-whh yont? •'~j~7~L~ ~{.p~~~' : ~,(' ~ ~ h.a v ~, Oct~patiori•(if-retii revjous nctatpetion)::- '~ . ~pr: q. ... 3'4 ~ ~-:;:.' ',~~' '„< Do u smo o.;;: ~ ,.1F'ta ..'-..... ,,w ' :#.o!' packs i~. If. the pstient~'~`:it they etcposest to ~ No j , L_ ~~:'-` :yi : ~ ~_ #;of: "ears - Ye',s~-"""° . ~ '~ .~ r + ': N• ~:; f'ix' '' ~ '' I)p u drinik=alco -No= Yee. ~ : = ~ a ~ ha~;yvu egdr ,.i~itised drugs? No % Yea ' , i-*;-` I;xpLaia • , ;<- Do you (or . 1 • " " " or abwed?, i~ Have ym1 ever~tieen phj+s9 - • i~~ ~ - , . •. ~ ~~: ~ .i `R!'haL latl~ui~;d0 SyO11 beZs'e • • ~ r. + ~~ ~ r ~ ~ ~ .. :4 t .How do bcerle.rn? : 'vVretteti ~ Veb ideo . ~ ~ .: ~ • x't-a .:,;: . PAST SUR,GFRIES / HOSPI'i'AIdZA'i~ONSi, ?^,;~?4 : ~ ` :Lane -~':. ;.~^%~~i ~ .~~; ' ::i,('. ` r ., J _ ;"~ 1~.: Y F A MILY M k;D I ~(~S- ~'w HISTORY (Pksise,~auuwer "yes";4I',"no°) `. ..~ . .. ~ . - 4 . ~ ' ~{ ~. ~ ~ ~~ r(( /++ ~~~~ 4il~Cet~ ~'^~_.V•:T. J.. X' ~Y.~ . ; ;i 5rrokc~ ~~~ :. ~ '~2~ ~ ~A8mm9:.., ~~~Y'; ~.a ~pl~fC~tl'*~lW~'_:~i .-:.:. ; ~!'F.?FS i f. ..y`. +F -_.. i ~ . • atfCtCB- :i ~~ . • • .i ... } ..,~ s ~ Di ' + .~'IZUt'[8~ ~ ~` 1~ ~t ~ t ~ .:!Giw^~.c. i'r ,^ 4 . EIcttrt Attack, Heort Diseabfe=' .•,^~,;" _. Otb~% -:1:. ... .. . PA ST MEDICAL. HIS'i~OIt~: REVIEW OP SY5T MS: ~ lave or Did" " u ever hauls? `:. ~ ` , ,... ' ` _.; . • Y N obkaii Comments.. . ~ ,. -: ,,..: Y . N. ... .,,. ; , Ptttbkms Comments. - ; . - . , = • .. ..f ... }' ...JtN t.:. .' ... ~.':. .. ..1- wheez' - - • i7ntieual Mosiic.W Numbness - "inic::bi»iu~i»ds ert seauC' C}ironic Fran - e . neumonia .4: <'~~:: sion ~'wia disuse bladder ~ s . ' sines nasal bletns~:::'~ ~ . ~ . 'H I:iver disease s i r' , Ct~ionk ate a ti 'toss: :s °.~ 3~IlV AIDS . - °` 'zr.c: . ~~ iVOiCG~Ot' mB'^..~'.'~5'i<;°kb.~ r. 1'tit ' sd~p'tjAj [ .,~•,.. ~.tiryri:.}?;; 'ha2:;;#,'.;k i#"`.~.:,"~ ' :~ . ~tenE n6uiies dlarri'iea"' -"''"?`:" ' ~ ' ~u:r#,~, >: ..• tioatic fever " :. • ,.:. :^,~;,; `Hcartbwn blaai[ h refhtx • ..... HEaritmiirmur ^,`~ tendenw . ..... ~... ... . . , <a... - ... n Iar heattiieat•..~ , :.:^ , ,,.::~c;; : • Skin bl2ini=': r.". , ~,rp:.:.,,: .. . ,ts7.: r:.. ~.:IlCit'•P.ain ;,:--, :_ ' .. Y,~; e. ~:al ,. ::DjYbetEL'. ,. ,.` ... .. .:..'sofa hcstrt Failure ~.: `:`: - '~'..' :. ~ . T 'd di tb id'mass ,. . H 'on -blood •esure . 'Artildtis bone or'oint roiitletlls ' 5 fatatl f ~e]Is ~LLI.DRENi .,~,~ .~.' - , .ST'r ~ ., y; 'in1117Nt11Zat10~11p:t'Fldafx'r'C:i::' ~i:~,:.:`~si:jn'.t..:•`~. «.ij:..:.y;:'.,, s~ •. syn. IlCAdaCl1e6.4'~.•. '. . . , ~ ~ :.Other: ~ ': ir+.•. '; ;2 .~, c~ . . - . ~ Strtiloc/Mitdattdie~ .: .: ,, :; }b[edicatwns ,.. . - AOer~ies, ' .:. ., ....... . ...:...: . .: -.: .. - ^ y~ z'..: - t1: r,:~.f• ~ Fa..a' ~.yb.f ....,. .., .~5. S'Ti:~~~'' ... "ica •wz .ii~~' ':t.: ~ • FC'e C.: . _•~~ '~`~~ ,;}.:: • ~~ •.~, .. -~: p.. ~ .a2 ,; y'`, f ~ IAIeY "~`~"SJ, ~: ~;; . •• Arc you (or thcpsiicntj cxperecncing anp pain today3:' • Ae~irin/Blood thfituer des }Vo o QYca } .. .. . . . ..' r..• _ .... .:.. dY .. ....i.NR. .: ~.~ ~.. t . ... ., ,.. j .. . ..:. ,. .... :. ..~' ~~ .. ~; . ... - :, obta~~a e«n:., r is _ ~~aa~,=":" t,: staff si~taiurc ~ ; lttl?VIEWED BY PHYSICIAN: M.D. MR 853 (Rsv. 51091 Palls 1 of 2 EDICAL HISTORY AND QUESTIONNAIRE Facility: Hospital Based Offices DATE~~~~ Page 5 of 8 Patient Name: GARLAND, TIARRA J Date of Birth: 10!3!2005 * Final' Chief complaint PHYSICAI, EJUM: (check normal or abnormal} 'Nicol Signs: vrt, ht_ BP~ T` P_ 8_ NomraF A4rwrma! ^ Getters! Appem~ancc -Well Nwttislud, Well Aereloped ^ ^ Bye. -Pupils, Lids, Sclera conjunctitrse ^ History-af Present lilnt:as: ^ Eon - cartels, Tympanic Membranes, hearir-g ^ ^ Nose -septum, tutbinases, tttucosa ^ ^ Or:d Crsvity-lips, game, teeth, nmgue, palate, tm~ue, ^ tonsils, Hoot at mouth lobo, Records, X-rays, Teats: ^ Phatyrot / Larynx J Voice ^ Proctdnres Done wilt Visit: (Flexible, Rtgtd, Strobe, Biopsy) - - .. -- Neck -Masses, Thyroid ^ ^ Respiratory/Lungs ^ ^ Cardiovaacular -Rhythm, Carotids, Marmots ^ DX: Follow-up Plon: ^ Abdomen ~ ^ ^ Skin - txlor, leaintrt ^ ^ Neurulty;ic -Cranial Ndrves iI-XII intact, gait ^ Time Discussing Plan Return Status: ~ Psychiatric -Judgement, Affect, Otieniatiott ^ Dn~ians: ~ 1~ x;81 _- ~ f izrol i)ictated (carte if dune Yhysleiar Slgnrtrre= , M.D, B.esldtrt Siggatrre: , LLD, t~ sss ~ sroe) Ptge z oe z DIVISION OF OTOLARYNGOLOGY-iiEAD AND NECK SURGERY ~aciYty: Hospital Based t~ffices MRN: 7506936 FIN; 14176746 Page 6 of S QENNS~ATE HERSHEY ~1~ Mil~.an S. Hershey ®A~ed.~ca1 Center Patient Name: GARLAND, TIARRA J MRN 7506936 ~~ibstarice W1~CA R'd~d ~?afef~ime ~2>~r.,orrl~~ (3y: 3/5!2010 22.13 EST Bedcer,Sarah Allergy History ' ,.... :Reaction Status Active; Allergy Type Allergy; Reviewed By Levan, :Jody; Reviewed DatelTime 3/11/2010 11:24 EST; Recorded On Behalf; :Of Bedcer,Sarah Date/Time Printed: 2/28/2012 12:46 EST Page 7 of 8 Printed By: Bender,5ylvia R PENNY SATE HERSHE~f Milton ~. Hershey medical Center Patient Name: GARLAND, TIARRA J MRN 7506936 ____________________............_.__.__._.__..____.____._______.__________..._.____ Problems ...______.__.___._..._._______._._________.._..._______.____._._______._________.__, problem .N..ame .:Laceration ~: .. ..._ ... -Last Updated: ~3/11/2010 11:21 EST;~Levan,Jody ,Classification. Medical; Corifirrnation: Confirmed; Code: 861.22; Course: ;Onset Date: ;Prognosis: ;Persistence: ,. Recorder: Lcvan,Jody; Responsiblo Provider: .. - ,, 1~rn~al~m Nam?. CLA~CLE f~( .. LastUpdated:~3/11/2010 11:20 EST; Levan,Jody ~~ ~~Classification: Medical; Confirmation: Confirmed;~Code 1310.00; Course: ;Onset Date: ;Prognosis: ;Persistence: f2ecorder: Levan,Jody; Responsible Provider: Date/Time Printed: 2/28/2012 12:46 EST Page 8 of 8 Printed By: Bender,Sylvia R EXHIBIT "6" COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY CASUALTY UNIT P.O.BOX 8486 HARRISBURG, PA 17105-8486 November 8, 2010 PROGRESSIVE INSURANCE CO. VERONICA SHIRK 3950 HARTZDALE DRIVE SUITE 150 CAMP HILL PA 17011-7828 Re: Tiarra Garland (minor) CIS #: 410333343 Co/Rec: 21/0090782 Incident Date: 03/05/2010 Claim #: 10-4708775 Dear Ms Shirk: In previous correspondence, you were informed of our claim regarding assistance payments made on behalf of the above-referenced individual. We understand you are the responsible primary carrier. Be advised the Department of Public Welfare maintains a claim against the proceeds of any award received by this recipient. This is detailed on the enclosed updated statement of claim. The statement does not include any other claims which may exist. If copies of bills are needed, please contact the providers directly. Refer them to the Medical Assistance Bulletin, No. 99-09-03 (Effective Date 03/20/09). At this time, please advise me of the status and also of your position regarding payment of the Commonwealth's claim. Sincerely, ~ r ,,, Barbara E. Witmer , Claims Investigation Agent °~~~ 717-772-6611 '.,, 717-772-6553 FAX ~~~ ~~ Enclosure ~ ' ,,,,<< r i I COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF FINANCIAL OPERATIONS TPL SECTION -CASUALTY UNIT PO BOX - 8486 HARRISBURG PA 17105-8486 November 8, 2010 STATEMENT OF CLAIM SUMMARY NAME GARLAND, TIARRA I D 410 333 343 UPDATE TO PREVIOUS SOC DATED 06/22/2010 MED-CAL USUAL CHA~tGES 'AMT APPROVED PREVIOUS SOC CURRENT SOC 34,562.93 .00 7,816.77 .00 PRIOR REIMB/ADJ (3,188.00) TOTAL 34,562.93 4,628.77 CASH PERIOD COVERED . DOLLAR AMOUNT PREVIOUS SOC CURRENT SOC -- - .00 .00 TOTAL .00 REIMBURSEMENT TO DPW 4,628.77 COMMUNWEALTH 01= PF_NNSYLVANIA L~E_PAR"iM[.1'd"f Ot= Piii3LIC Wf_LI=F,iZI? EIN - 23-6003113 ~2 ~~ ~v-f I ~, ,~;~ .~, ~~<<,. <<,~ r ,:.... . ,~ ' COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BURFP,U OF PROGRAL! INTE6RIlY DIVISIOP! OP TL'IRD P?.R h( I_!i',']It_I i f CASUALTY UNIT P.O.BOX 6486 HARRISBURG, PA 1 7 1 05-8466 November 4, 2010 RISING MEDICAL SOLUTIONS 700 W VIRGINIA ST STE 401 MILWAUKEE WI 53204 Re: Tiarra Garland (minor) CIS #: 410333343 Incident Date: 03/05/2010 Dear Sirs: This is to acknowledge receipt of payment in the amount of $3,188.00 regarding the above-referenced individual. Your cooperation in this matter is appreciated. "''-" Sincerely, 1.~~~±.c~ `~S~~GCeu Barbara E. Witmer Claims Investigation Agent 717-772-6611 717-772-6553 FAX .,. ,~ ,, .~, ,,..~. ,~, , „~ <<„~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY CASUALTY UNIT P.O.BOX 8488 HARRISBURG, PA 17105-8486 June 22,.2010 PROGRESSIVE INSURANCE CO. VERONICA SHIRK 3950 HARTZDALE DRIVE SUITE 150 CAMP HILL PA 17011-7828 ~~11C~`' Re: Tiarra Garland, (minor) CIS #: 410333343 Incident Date: 03/05/2010 Claim #: 10-4708775 Dear Ms Shirk: We understand that you are the insurance carrier handling the above- referenced claim. This is to advise you that the Pennsylvania Department of Public Welfare has a medical assistance claim. Under Pennsylvania law, the insurance carrier has an independent obligation to assure satisfaction of the Department's medical assistance claim. It is the carrier's obligation to assure payment of this claim before making any payment or distribution to the claimant or his attorney. 62 P.S. §1409 (b)(9). If payment of the medical assistance claim is not made, the insurance carrier may be obligated to pay twice. No settlement with the claimant will discharge the medical assistance claim against your company and your insured unless satisfactory arrangements are made with the Department of Public Welfare. As the obligor responsible for paying the claimant's medical and income loss benefits, you have a statutory obligation to reimburse the Department of Public Welfare directly, 23 P.S. §4326(G)(1), for all medical and/or cash assistance preliminarily provided on behalf of the injured claimant. Additionally, 62 P.S. §1406(a), clearly states that payment made to a provider by the Department of Public welfare is payment in full. For this reason, you are obligated to make payments directly to this office. The Department's claim for medical assistance reimbursement may also include a claim for cash assistance reimbursement. Under 62 PA. C.S.A. §1974, as amended by Act 43 passed by the General Assembly July 7, 2005, cash assistance must also be repaid from the proceeds of a personal injury claim. No settlement you negotiate with the tortfeasor or his insurance company will discharge the Department's claim for medical or cash assistance reimbursement without first satisfying or assuring satisfaction of the interest of the Commonwealth. The Third Party Liability Section will assist you by providi~t~;the~~~~ information about our claim. Please be aware that any information that we provide you must be safeguarded, and used by you solely to reco~~~'r',funds which we provided. Disclosure for other purposes may subject yotz~co crim=nal or civil penalties. ~ ~ r; ' ~ , ~ , If copies of bills are needed., please contact the providers directly. Refer them to the Medical Assistance Bulletin, No. 99-09-03 (Effective Date 03/20/09). Fr ~i ~~sed. is a. statement of :~ .. a .... .: . J .~. ,~:i.la; t. ,.a.c1 L:~ .. A~.e by ~,h.e ~epa~ crc:.,~~_c of i'u~J_ic Welfal.<: on behalf of tt~.~ aaove-referenced individual. The provider name, dates of service and the amount approved by the Office of Medical Assistance are included. Since additional medical and/or cash assistance may be granted, please contact our office one month prior to settlement so that we can provide you with an updated statement of claim. Social Security Act §1902(a}(7) requires that this recipient information be safeguarded, used by you solely to recover funds which we provided. Disclosure for other purposes is subject to criminal and monetary penalties. Checks should be made payable to the Department of Public Welfare and sent to my attention. Please use the return address from page one. Please contact this office well in advance of settlement so that we can provide you with a current statement of claim. We would appreciate if you would keep us informed of the status of this case. If first party benefits were exhausted, please provide a list of providers paid. If you have any questions, please contact me. Your cooperation will be appreciated. Sincerely, ~ r ~~.~~~~ Barbara E. Witmer Claims Investigation Agent 717-772-6611 717-772-6553 FAX Enclosure ~ rr r ~ ~ ~ ' '+ tl ~ COMMONWEALTH OF PENNSYLVANIA DEf';`.^ f ';;=bdT 0'= ?U31_IC INELi=ARE 171_ SFCI-:.~:! - :...St_l: J.-i~; ~';'IT HARRISBURG PA 17105466 June 22, 2010 STATEMENT OF CLAIM SUMMARY NAME GARLAND, TIARRA ID 410 333 343 MEDICAL USUAL CHARGES AMT APPROVED CLAIMS 34,562.93 7,816.77 CASH PERIOD COVERED DOLLAR AMOUNT CURRENT SOC - .00 ,-- REIMBURSEMENT TO DPW 7,816.77 ` `, , `, COMMON~VLAC Fi OF PEid~VS i"LVe !iA DEPARTML!! 1 OF PUBLIC !/VI-I_F; . , _ - EIN - 23-0003113----------..`-------~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE I June 22, 2010 STATEMENT OF CLAIM NAME GARLAND, TIARRA ID 410 333 343 FEDOK FRED G 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 04/06/10 - 04/06/10 v 04/29/10 01050734701 32101381833120001 114.00 47.32 DIAGNOSIS 1 : 8798 OPEN WOUND SITE NOS PROC CODE : 99212 OFFICE OR OTHER OUTPATIENT YISIT FOR THE PROVIDER SUB TOTAL FEDOK FRED G 114.00 47.32 31 001168400 0002 NPI: 1760449656 ~~ < , NCFret COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 22, 2010 . , . ,~.,._.. ~ .. ~ . , _,'.IE.'r NAME GARLAND, TIARRA ID 410 333 343 GOLDENBERG DAVID 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/12/10 - 03/12/10 04/12/10 00830777801 32101381251940001 114.00 47.32 DIAGNOSIS 1 : 8798 OPEN WOUND SITE NOS PROC CODE : 99212 OFFICE OR OTHER OUTPATIENT VISIT FOR THE PROVIDER SUB TOTAL GOLDENBERG DAVID 114.00 47.32 31 101459482 0001 NPI: 1578520847 ~' ~k~~ ~,~, , COMMONWEALTH OF NENNSYLV!\PlIA DEPARTMENT OF PUBLIC WELFARE June 22, 2010 STATEMENT OF CLAIM NAME GARLAND, TIARRA ID 410 333 343 ARMSTRONG DOUGLAS G 30 HOPE DRIVE ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/11/10 - 03/11/10 04/12/10 00810635501 32101381315290001 162.00 63.70 DIAGNOSIS 1 : 81000 FX CLAVICLE NOS-CLOSED PROC CODE : 99213 OV/OP VST FOR EVAL 8~ MGMT OF ESTAB PAT PROVIDER SUB TOTAL ARMSTRONG DOUGLAS G 162.00 63.70 31 102208899 0001 NPI: 1467486712 «~ r ~ ' <<<~~~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 22, 2010 NAME GARLAND, TIARRA ID 410 333 343 FAGELMAN KERRY M 2600 N 3RD S7 ARRISBURG PA 17110 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03H1/10 - 03!11110 04!12/10 00810651001 32101381816840001 162.00 63.70 DIAGNOSIS 1 : 9598 INJURY MLT SITElSITE NEC PROC CODE : 99213 OV/OP VST FOR EVAL 8 MGMT OF ESTAB PAT PROVIDER SUB?OTAL FAGELMAN KERRY M 162.00 63.70 31 000963672 0001 NPI: 1679539621 ~ ~ «r~ r t ~ " r b ~~ iii ~ ~ ~ i. i. i. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 22, 2010 STATEMENT OF CLAIM NAME GARLAND, TIARRA ID 410 333 343 MCGINN JOHNATHAN D 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03!06110 - 03/06/10 03/29/10 00690785601 32101171433240001 331.00 54.60 DIAGNOSIS 1 : 9108 SUPERFIC INJ HEAD NEC PROC CODE : 99253 INITIAL INPATIENT CONSULTATION FOR A NEW PROVIDER SUB TOTAL MCGINN JOHNATHAN D 331.00 54.60 31 001840514 0006 NPI: 1831156728 . , „ V4d ~'t•tl COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 22, 2010 STATEMENT OF CLAIM NAME GARLAND, TIARRA 1D 410 333 343 POTT LEONARDUS M 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03105/10 - 03/05/10 03/31/10 00780716501 32101172083350001 114.00 110.78 DIAGNOSIS 1 : 9598 INJURY MLT SITE/SITE NEC PROC CODE : 99243 OFFICE CONSULTATION FOR A NEW OR ESTABLI PROVIDER SUB TOTAL POTT LEONARDUS M 114.00 110.78 31 100889326 0001 NPI: 1437109295 f' F t f t ~. COMMONWEALTH OF PENNSYLVANIA DEPARl-MENT OF PUBLIC LVELFARE June 22, 2010 STATEMENT OF CLAIM NAME GARL.-.NIA, TIARRA ID 410 333 343 ENGBRECHT BRETT W 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/05/10 - 03/05/10 03!29/10 00700654901 32101172069680001 4,268.00 275.62 DIAGNOSIS 1 : 9598 INJURY MLT SITEISITE NEC PROC CODE : 99245 OFFICE CONSULTATION FOR A NEW OR ESTABLI 03/06/10 - 03/06/10 03/29/10 00690732801 32101172069590001 DIAGNOSIS 1 : 9598 INJURY MLT SITE/SITE NEC PROC CODE : 99238 HOSPITAL 191.00 30.94 PROVIDER SUB TOTAL ENGBRECHT BRETT W 4,459.00 306.56 31 101386680 0001 NPI: 1932165479 `~,.Y ,~. eroc e~ COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 22, 2010 STATEMENT OF CLAIM NAME GARLAND, TIARi2A 1D 410 333 343 OLYMPIA ROBERT P 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/05!10 - 03/05N0 03I31J10 00760590201 32101171628850001 470.00 72.00 DIAGNOSIS 1 : 9598 INJURY MLT SITE/SITE NEC PROC CODE : 99285 EMERGENCY DEPARTMENT VISIT FOR THE EVALU PROVIDER SUB TOTAL OLYMPIA ROBERT P 470.00 72.00 31 101403816 0001 NPI: 1568410793 <<„ ` ~ M < 1 4 ~ l!F.C Pf f ^! COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 22, 2010 S i"ATEMENT OF CLAIM NAME GARLAND, TIARRA ID 410 333 343 NGUYEN- DAN T 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES .AMOUNT APPROVED 03/05!10 - 03105!10 03129!10 00710572601 32101172078040001 352.00 56.52 DIAGNOSIS 1 : 9309 FOREIGN BDY EXT EYE NOS PROC CODE : 70450 COMPUTERIZED AXIAL TOMOGRAPHY, HEAD OR B 03/05/10 - 03105N 0 03/29/10 00710572602 32101172078040002 470.00 75.59 DIAGNOSIS 1 : 9309 FOREIGN BDY EXT EYE NOS PROC CODE : 70486 COMPUTERIZED AXIAL TOMOGRAPHY, MAXILLOFA PROVIDER SUBTOTAL NGUYEN DAN T 822.00 132.11 31 101430241 0001 NPI: 1598753618 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARF_ f RITE AID PHARMACY #3611 455K N ENOLA RD June 22, 2010 STATEMENT OF CLAIM NAME GARLAND, TIARRA ID 410 333 343 NOLA PA 17025 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03!06!10 - 03/06!10 03/15N0 35100821369940001 35100821369940001 47.99 18.40 DIAGNOSIS 1 : 0 NDC CODE : 00093417773 CEPHALEXIN 250 MG/5 ML SUSP - CEPHALOSPORINS PROVIDER SUB TOTAL RITE AID PHARMACY #3611 24 100729298 0635 NPI: a7.99 18.40 ,. ` ~`~ ~ ~ , t <<<<i~ ;FI COMMONWEALTH OF PENNSYI_VAi~!IA fI DEPARTMENT OF PUBLh WELFAF'r NAME GARLAND, TIARRA 1D 410 333 343 PENN STATE THE MILTON S HERSHEY MED 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03/05!10 - 03106/10 03/31/10 007613797 32101173802810001 14,448.20 3,584.10 DIAGNOSIS 1 : 81000 FX CLAVICLE NOS-CLOSED DIAGNOSIS 2 : 8505 CONCUSSION W COMA NOS PROC CODE : 000000 03/05/10 - 03/05/10 DIAGNOSIS 1 : 95901 DIAGNOSIS 2 : 9598 PROC CODE : A0431 03/05!10 - 03/05110 DIAGNOSIS 1 : 95901 DIAGNOSIS 2 : 9598 PROC CODE : A0436 05/12/10 01270217401 32101557748780001 11,839.00 3,172.00 HEAD INJURY, UNSPECIFIED INJURY MLT SITE/SITE NEC AMBULANCE SVC,CONV AIR SVC,ONE WAY(ROTAR 05/i2/10 01270217402 32101657748780002 268.00 16.32 HEAD INJURY, UNSPECIFIED INJURY MLT SITE/SITE NEC ROTARY WING AIR MILEAGE, PER STATUE MILE PROVIDER SUB TOTAL PENN STATE THE MILTON S HERSHEY MED CTR 26,555.20 6,772.42 24 100765310 0034 NPI: 1467408211 COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 22, 2010 STATEMENT OF CLAIM NAME GARLAND, TIARRA ID 410 333 343 WEST SHORE ADV LIFE SUP SVC 503 N 21ST ST AMP HILL PA 17011 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNTAPPROVED 03!05110 - 03!05/10 03/31!10 00822301501 32101171316040001 903.74 80.00 DIAGNOSIS 1 : 95901 HEAD INJURY, UNSPECIFIED PROC CODE : A0432 PARAMEDIC INTERCEPT,RURAL AREA,TRANSPORT PROVIDER SUB TOTAL WEST SHORE ADV LIFE SUP SVC 26 001173277 0001 NPI: 1518960749 903.74 80.00 " „ r ~ ~ ` ` ~ l t ~ t L {": ( i I COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE June 22, 2010 NAME GARLAND, TIARRA ID 410 333 343 BOAL DANIELLE 500 UNIVERSITY DR ERSHEY PA 17033 DATE OF SERVICE PAYMENT DATE ORIGINAL CRN ADJUSTED CRN USUAL CHARGES AMOUNT APPROVED 03!05/10 - 03l05N 0 03/29/10 00710570301 32101171848040001 75.00 10.80 DIAGNOSIS 1 : 81000 FX CLAVICLE NOS-CLOSED PROC CODE : 71010 RADIOLOGIC EXAMINATION, CHEST; SINGLE VI 03/05/10 - 03/05!10 03/29!10 00710570302 32101171848040002 75.00 12.12 DIAGNOSIS 1 : 81000 FX CLAVICLE NOS-CLOSED PROC CODE : 73030 RADIOLOGIC EXAMINATION, SHOULDER; COMPLE 03/05/10 - 03/05/10 03/29/10 00710570303 32101171848040003 68.00 10.54 DIAGNOSIS 1 : 81000 FX CLAVICLE NOS-CLOSED PROC CODE : 73000 RADIOLOGIC EXAMINATION; CLAVICLE, COMPLE. 03/05!10 - 03/05/10 03/29/10 00710570304 32101171848040004 90.00 14.40 DIAGNOSIS 1 : 81000 FX CLAVICLE NOS-CLOSED PROC CODE : 72040 RADIOLOGIC EXAMINATION, SPINE, CERVICAL; .PROVIDER SUB TOTAL BOAL DANIELLE 308.00 47.86 31 000667165 0001 NPI: 1588621775 ~, ~ ~ r i ~~ ~ ~~ t c ~ ~ ~ ~. COMMONWEALTH OF PENNSYLVANIA DEPARTMENT OF PUBLIC WELFARE BUREAU OF PROGRAM INTEGRITY DIVISION OF THIRD PARTY LIABILITY CASUALTY UNIT P.O.BOX 8486 HARRISBURG, PA 17105-8486 September 14, 2010 PROGRESSIVE INSURANCE CO. VERONICA SHTRK 3950 HARTZDALE DRIVE SUITE 150 CAMP HILL PA 17011-7828 Re: Tiarra Garland (minor) CIS #: 410333343 Incident Date: 03/05/2010 Claim #: 10-4708775 Dear Ms Shirk: Pursuant to your request, please be advised that the Department's statement of claim dated 06/22/10 in the amount of $7,816.77 is current. Thank you for your cooperation in this matter. If you have any questions, please contact me. Sincerely, ~ r ~. ~~ Barbara E. Witmer Claims Investigation Aqent 717-772-6611 717-772-6553 FAX EXHIBIT "7" a a vpa cool vc ~.ao auo ~.~ PROGRESSNE P.O. BOX 31260 TAMPA, FL 33631 JOHN P ATTICKS 155 AMY DRIVE CARLISLE, DA 17013 Auto Insurance Coverage Summary This is your Declarations Page Your coverage has changed t(tJ U U L PR~l9f.J:f/(/E' DYRECT Policy number. 500x5966.1 underwritten bY: Progressive Advanced insurance Co March e, 2010 Policy Period: Oct 22, 2009 -Apr 22.2010 Page 1 of 2 progressive,com online Swig Make paymems, dick billing activity, update policy information rX check staWs of a daim. x00-PROGRESSNE (800.776.4737) For customer service and claims service. z4 hours a day, 7 days a week. Your coverage began on October 22, 2009 at 11:01 a.m. This polity expitrs on April ZZ, 2010 at 12;01 a.m. This coverage summary replaces your prior one. Your insurance polity and any polity endorsements contain a full explanation of your coverege. The policy contract is form 9610D PA (OS/06). The contras is modified by forms 2357 (01/07) and 2445 PA (03/07) COLLISION COVERAGE FOR RENTAL VEHICLES IF THIS POLICY PROVIDES COLLISION COVERAGE, IT WILL APPLYTO VEHICLES YOU RENT, BUT NOT TO VEHICLES RENTED FOR 6 MONTHS OR MORE, Policy changes effective February 18, 2010 Premium change :................................... ..........~........, ,,.,.,,.........................,........................,,,,,.,.,,............. Cfenges:. .. ,~~ .~" ......... ......~",..,.,...........The 1998CIievroletBlazer~tes~beeri~added.... ..,.. ~",.... .. ..... ",~~..,. The 1995 Acura Integra LS has been removed. Underwriting Company Progressive Advanced Insurance Co P.O. Box 31260 Tampa, FL 33631 800-776-4737 Drivers and household residents 10HN P ATTICKS Additional iMarmodon Rrst Named insured ~~~~~~~~~~~ ~~~~ ~ ~~~~~ Fain 6~e9 PA (pU071 E Coadnued 1 V/ V L r L V 1 L l V V 1 l A A r L Y , i V 1 L V Y 1 1 V f~ 1 C D O 1 V C V Q O 14 O V V Outline of coverage ~1JUUJ Policy number. 50085966.1 IOHN PATTICKS Page 2 of 2 1996 Chevrolet Blazer VIN 1GNDT13WSW22977Z3 .......... ................. .............. ~ limps .......... tk4uNDle Premium Liability To Others . .......................................................~..... ........,,,.,,,,,,......~ Bodily Injury liability 525,000 each personl$50,000 each accident Property Damage Liability .. ~ $25,000 each accident ................... ..................... Fat Parry eenefits ....................... ............................................. ............................~ Medial Expenses ~~ ~~ . 55,000 each person ...................... Uninsured Motorist-Stacked ~•~ ~ ~~ ~~ ~ ..525,000 each peaorVS50,000~each~atxide~~~ ~ ~ ~ ~~ ~~~ ~~~~ ~ ~~~~~~~ ~~~~~ Underinsured Motorist-Stacked ,,.. .,. .. . . . S25,000.each personlS50,000eachacadent ~ ~~~ ~ ~ Total 6 month policy premium .,. . .,. . , , ....... ......' Premium discounts PaGry 500@5966-1 electronic funds Uansfer (EFT) Vehicle 1998 Chevrolet Bla2er ..................... ................. ..airbay.,....................,,,,..................,.,..,............ . „ ...,.. _......... ,,,,,. Tort Option This policy provides limited tart insurance. Information Regarding Your Premium A surcharge of due to violations a acciderrts is included in the total policy premium. Company officers i~, ~ President Secretary Porm 6489 PA ra4,on EXHIBIT "8" _ __ _ _ _ ~~~ 11/lD/LU1L 14:Ua rNA !L4 /In 1LUY rrogressive cas ins c;o . .- .~- ~- AFI~H}AVXT~'~T~ EX~E~S L-~A~~TY IP~FS~~-_ .. __.~ _. tQJ 0 U 3 I, John P. Atticks, residing at 155 Amy Drive, Carlisle, PA 17013, being duly sworn according to law, deposes and attests: l . That my vehicle was involved in an automobile accident on March S, 2010; 2. That I did own the 1998 Chevrolet Blazer, which was insured by _.. 1?ro~essive Advanced Insurance Company, u~-der policy number 50085966~I, at the time of this accident; 3. That 1 do not have any excess /umbrella insurance in effect on March S, 2010 which would provide additional coverage for this loss. // 7/~ z . i;~tlature Date On this day of ~,~, , 20~, before me personally appeared f ~ f~[LY ~~LSL~-, to me known to be the person who executed the foregoing instrument, and acknowledged tltis 9s a free act and deed. [N TE~SITIMONY WHEREOFI~I~h~av'e,.h~elr~eto subscribed my name and affixed my seal this / ~ day o~f _ ~ C u`~~f~Xl`i'~ , 20~~ ~ - _ ~ .. My commission expires~~~~~3 Stste v~ A Conaty ~of NOTARIAL SEAL _ _ _ V ~ - - v - _ ° V OEBRA L GOGGIN ~ ~ ...- - - _ Nobry Pualic ~ ` _ ~ _ _ HIGHSPIRE 80R0., DAUPHIN COUNTY _ -- ' - - ~ -~ My Commission Expires Apt 5.2013 _ - _ = EXHIBIT "9" October 3.2012 Jennifer Oprosky Claims Specialist Sr -Lit Progressive Insurance 6021 Wallace Road Extn Suate 110 Wexford, PA 1 logo Re: Our Insured: Nancy Garland/Tiarra Garland Our Claim Number: NR-NSA-4149777-030510-B Your Claim Number: 104708775 Dear Ms. Oprosky: ~~'FSTI~IE~.D ti4~ (!. .'*~.. t We understand that Progressive is in the process of resolving a third party claim for Tiarra Garland, who was injured in a motor vehicle accident with yourr insured on March ~, 2010. In response to your request for consent to settle, please be advised that without waiver of the terms and conditions of the Westfield policy, we heareby waive subrogation and grant you consent to settle. This decision is no way meant to imply that the Progressive policy is insuf~i.cient to compensate Ms. Garland, nor that she is entitled to underinsured. motorist benefits under the Westfield policy. Please contact the undersigned with any questions. Be ards, Je Shumway AIC Litigation Specialist . _ ,~r . ,